Protocols That Fail to Ensure the Precision of

Written Protocols

Forensic Standard 11.1 requires that forensic DNA laboratories follow written procedures for taking and maintaining case notes to support the conclusions drawn in laboratory reports. Further, Forensic Standard 11.1.1 requires that forensic DNA laboratories maintain, in a case record, all

documentation generated by examiners related to case analyses. The DNAUI’s protocols refer to these requirements and address, in a limited way, the

documentation that should be present in a case file. However, we did not find comprehensive guidance on notetaking methods in three sections of the

protocols where manual notetaking is identified as a significant part of staff member responsibilities. In addition, the sections lacked an explicit

requirement for staff members to complete their notes contemporaneously with their work. The three sections are: 1) the Case Documentation Policy within the FBI Laboratory Division Quality Assurance Manual; 2) the Evidence Control section within the DNA Analysis Unit I Quality Assurance Manual; and 3) the

Procedures for the Examination of Evidence within the FBI Laboratory Division Caseworking Procedures Manual.

The team structure in DNAUI makes it especially important that all staff members have a comprehensive and consistent understanding of how to record information as they complete their work. The case file documentation created by the Serologists and PCR Biologists serves a crucial role in communicating to the Examiner the results of the DNA analyses they have performed. The

Examiner draws conclusions from this work and often testifies in court based in part on the documentation contained in the case file.

In addition, contemporaneous documentation is important to ensure that the case file accurately reflects the work performed on each evidence item that is tested. If staff members are allowed to delay recording observations and test results until after they have examined all the items for a case or have

completed all of their work for the day, their documentation may not be fully accurate. Also, staff members may be unduly influenced by protocol

requirements when relying on memory, and document what they know should have occurred when their recollection is vague. Such a situation could lead to difficulties when trouble-shooting testing problems. For example, a weak and unusable testing result might be caused by a sample with low quantities of DNA or by a technical problem in the analysis process. An Examiner reviewing such results may not be able to pinpoint how to generate a better outcome if he or she is provided with an incomplete record from a staff member who is

Interviews

Because we could not find any requirement for contemporaneous

documentation or comprehensive guidance on how staff members should take notes, we asked staff members and management what they believe the

requirements are on this subject. We interviewed ten DNAUI staff and three members of DNAUI management.

DNAUI management cited a specific section of the protocols as the source of guidance on notetaking. However, the five staff members who cited the same section stated that the guidance in the protocols is very general and does not fully address the subject. Two staff members stated that notetaking is

addressed in the protocols but did not cite a specific section. Three of the ten staff members stated that they did not think the protocols addressed the

subject at all. Six of the ten staff members stated that documentation methods are learned during training.

Unit management stated that notes are taken contemporaneously as testing is performed. Staff members generally indicated that they take handwritten notes as they work and then transcribe the notes into the

computer at a later time (typically on the day they are written). Further, staff members did not always give the same answers regarding the time when they take notes: one Serologist stated that staff members will process multiple items and then type up notes; another Serologist explained that staff members create notes immediately after processing each item; and a PCR Biologist stated that staff members would not “typically” put off transcribing their notes until the following day (indicating that there might be times when that does occur).

We also noted from interview responses that for those staff members who are taking contemporaneous notes on their computer during their work, there are no policies in place that require a protective covering (such as plastic wrap) to be used and changed at appropriate intervals to prevent contamination or cross-transfer as the staff person moves from handling an evidence item to typing on the computer keyboard. This issue is of greater concern now that the DNAUI has moved to its new facility. During our tour of the new Laboratory, the Unit Chief explained that the serology and PCR Biologist areas are

equipped with a computer for each workstation to permit the immediate transfer of examination and analysis notes into the computer. He further stated that with the addition of these workstations staff members are expected to complete their notes contemporaneously with their work.

Given the disparities in staff member answers, we concluded that Laboratory management has not clearly articulated standards to govern notetaking, including handwritten notes that are later transferred to the computer. Further, it is evident from the Unit Chief’s responses that while contemporaneous documentation previously was a goal, it now is an

expectation in the new facility. No written requirement has been published for staff members, however, setting forth comprehensive guidance on notetaking methods.

Recommendations

We recommend that Laboratory and DNAUI management:

18) Supplement documentation guidance found within the Case

Documentation Policy in the FBI Laboratory Division Quality

Assurance Manual, the Evidence Control section in the DNA Analysis Unit I Quality Assurance Manual, and the Procedures for the

Examination of Evidence in the FBI Laboratory Division Caseworking Procedures Manual, to include comprehensive guidance on

notetaking methods.

19) Require staff members to document contemporaneously the testing performed in each case.

20) Include in the Unit-specific protocols cleaning and decontamination techniques designed to reduce the risk of contamination or cross- transfer as staff members move back and forth between the evidence items they are examining and their computer keyboards to take notes.