Background The revised BASHH guidelines for the management of sexual assault were published in 2011. Introduction of a new electronic patient record (EPR) at a sexual health clinic provided an opportunity to audit the management of sexual assault.

Aims To review the clinical care of complainants of sexual assault against the auditable outcome measures identified in the guidelines.

Methods The EPR of patients attending between 1 August 2010 and 31 July 2011 was searched using the term “assault.” Cases reporting a sexual assault for the first time were included and reviewed against the auditable outcome measures. Demographic data and sexually transmitted infection (STI) test results were recorded.

Results 236 records were identified but 99 cases fulfilled the inclusion criteria. Of the 14 auditable outcomes, only HIV risk assessment reached the 100% standard and seven achieved above 60% concordance (offer and provision of HIV post-exposure prophylaxis, emergency contraception, follow-up tests, forensic medical examination, hepatitis B vaccine and detailed history of assault). Child protection assessment was documented in 57% of under-19s. 28% had the recommended STI tests and 16% were offered STI prophylaxis. There were no self-harm risk assessments documented. STI prevalence was: Gonorrhoea 8%, Chlamydia 9%, HIV 2%, Hepatitis C Virus and Trichomonas 1%.

Conclusion Low STI testing rates overall are explained by Hepatitis B and C testing not previously being a requirement unless there was a specific risk identified. The clinic conducts an automatic risk assessment for under-16s but not for under 19s. STI prevalence was high. A sexual assault pro-forma will be recommended and improved documentation is required.