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STI/Limited Consent form (pg. 1)
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STI/Limited Consent Form (pg. 2)
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In-Take Information
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Patient age at time of exam
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SANE Nurse(s)
• • •
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SANE Dispatch Time
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SANE Arrival Time
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Patient Arrival Time
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Patient Discharge Time
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Language
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Interpreter Name, #, Agency
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Patient Accompanied By
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Referral Source
• • •
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Other Referral Source
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Present During SANE Medical History
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Present During SANE Exam
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Date of Assault
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Follow-Up Contact Requested
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Police Report
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Ok to Call
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Officer/Det Name & Agency
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Sexual Assault Medical History
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Anal Injuries/Sympt Prior to SA
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Genital Symptoms Prior to SA
• • •
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Other Pertinent Injuries/Symptom
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Oral Injuries Prior to Assault
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Any Alcohol within 48 hours?
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If yes, amount/time of ingestion
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SA Related to Domestic Violence?
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Offender Information
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Name of suspected offender(s)
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Offender Relationship
• • •
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Number of Offenders
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Offender Gender
• • •
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Describe Family Relationship
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Offender Age(s)
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Condom Used
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If yes, describe
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Use of Weapon
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If yes, describe
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Use of Force
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If yes, describe
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Use of Threat
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If yes, describe
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Position of Authority
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If yes, describe
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Patient Affect/Demeanor
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Eye Contact
• • •
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Other
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Speech
• • •
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Other
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Responsive to Clinician
• • •
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Other
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Non-Verbal Expressions/Behaviors
• • •
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Other
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Appearance
• • •
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Other
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Comments on abnormal appearance
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Other Comments on Demeanor
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SANE Physical Exam
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Pain Scale
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LMP
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Current Immunization Status
• • •
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Past Medical History
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Past Surgical History
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General Assessment~Normal
• • •
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General Assessment~Abnormal
• • •
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Additional General Comments
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Head Assessment~ Normal
• • •
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Head Assessment~Abnormal
• • •
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Additional Head Comments
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Eye Assessment~Normal
• • •
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Eye Assessment~Abnormal
• • •
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Additional Eye Comments
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Ears Assessment~Normal
• • •
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Ears Assessment~Abnormal
• • •
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Additional Ears Comments
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Nose Assessment~Normal
• • •
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Nose Assessment~Abnormal
• • •
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Additional Nose Comments
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Oropharynx Assessment~Normal
• • •
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Oropharynx Assessment~Abnormal
• • •
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Additional Oropharynx Comments
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Neck Assessment~Normal
• • •
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Neck Assessment~Abnormal
• • •
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Additional Neck Comments
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Cardiovascular Assessment~Normal
• • •
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Cardiovascular Assessment~Abnormal
• • •
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Additional Cardiovascular Comments
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Pulmonary Assessment~Normal
• • •
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Pulmonary Assessment~Abnormal
• • •
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Additional Pulmonary Comments
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Abdomen Assessment~Normal
• • •
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Abdomen Assessment~Abnormal
• • •
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Additional Abdomen Comments
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Skin Assessment~Normal
• • •
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Skin Assessment~Abnormal
• • •
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Additional Skin Comments
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Musculoskeletal Assessment~Normal
• • •
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Musculoskeletal Assessment~Abnormal
• • •
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Additional Musculoskeletal Comments
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Breast/Chest Assessment~Normal
• • •
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Breast/Chest Assessment~Abnormal
• • •
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Additional Chest/Breast Comments
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Upper Extremities Assessment~Normal
• • •
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Upper Extremities Assessment~Abnormal
• • •
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Additional Upper Extremities Comments
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Lower Extremities Assessment~Normal
• • •
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Lower Extrem Assessment~Abnormal
• • •
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Additional Lower Extremities Comments
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Neuro Assessment~Normal
• • •
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Neuro Assessment~Abnormal
• • •
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Additional Neuro Comments
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Psychiatric Assessment~Normal
• • •
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Psychiatric Assessment~Abnormal
• • •
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Additional Psychiatric Comments
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Suicide Assessment
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Non-Fatal Strangulation Assessment
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Offender Slapped Pt. Open Hand
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Location
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Offender Slapped Pt. Open Hand
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Location
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Offender Hit Pt. with Fist(s)
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Location
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Offender Hit Pt. with Object(s)
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Location
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Offender Bit Patient
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Location
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Patient Bit Offender
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Location
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Did Patient Injure Offender
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If yes, describe:
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Manner of Strangulation
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Neck pressure felt during strangulation incident(s) on a 0-10 scale
• • •
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Additional Comments
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How Long did the strangulation(s) last? (Seconds/minutes/cannot recall
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Additional Comments
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How many times did the strangulation(s) occur ?
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Additional Comments
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What made the assailant stop strangling the patient ?
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Patient position and location following the strangulation incident(s)?
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Patient position and location prior to strangulation incident?
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Methods of Strangulation
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Assailant was:
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Methods of Strangulation
• • •
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Pt. Comments Related to the Methods of Strangulation
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If Ligature: Name/description
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Type of Strangulation(s) Occurred ?
• • •
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Was the Patient Smothered ?
• • •
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If "Yes": Describe
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Was the patient shaken during the incident ?
• • •
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If Shaken: Describe
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Did the assailant apply pressure to your chest or upper abdomen ?
• • •
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If pressure was applied: Describe
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Was the patients head or face pound against any object during the incident ?
• • •
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If head or face was pounded: Describe
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Was the patient slapped, kicked, punched, or bitten anywhere ?
• • •
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If slapped, punched, bitten, or other: Describe
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Was the assailant wearing any jewelry on hands or wrists ?
• • •
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If "Yes": Describe
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Have you been strangled prior to this event ?
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Was the patient sexually assaulted ?
• • •
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What did the assailant say before, during, or after the strangulation(s) ?
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What did the patient think was going to happen during the strangulation?
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Additional Comments
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Strangulation Physical Assessment #1
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Strangulation Physical Assessment pg 2
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Strangulation Physical Assessment pg 3
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Strangulation Physical Assessment pg 4
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Emergency Services Referred/Required
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Urine Dip
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Glucose
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Bilirubin
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Ketones
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Specific Gravity
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Blood
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pH
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Protein
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Urobilinogen
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Nitrites
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Leukocytes
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SANE Patient Medical History of Events
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Historian/Caregiver Comments to History of events
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SANE Patient Medical History of Events
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SANE Summary of Acts
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Penetration of Female Genitalia
• • •
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Comments
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Penetration of Anus
• • •
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Comments
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Oral Copulation of Genitals
• • •
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Location:
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Oral Copulation of Anus
• • •
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Location
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Masturbation
• • •
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Location
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Did Ejaculation Occur?
• • •
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Location
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Fondling of Patient
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Location
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Offender Licked Patient
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Location
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Offender Kissed Patient
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Location
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Offender Bit Patient
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Location
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Offender Sucked Patient
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Location
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Patient Bit Offender
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Location of Injury
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Did Patient Injure Offender
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If yes, describe:
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Additional Comments
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Clothing Information
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SANE Clothing Information
• • •
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Clothing Photo Documentation & Photo Numbers
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Clothing Collected
• • •
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Type of Film
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Additional Medical Treatment
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Additional Medical Consultation
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Physician
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Additional Reporting
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Adult Protective Services Needed
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Caseworker Name & Phone Number
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Other, Agency/Contact Info
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Comments
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Location
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Adult Pharmacy Log
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Acetaminophen
• • •
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Lot # & Exp. Date
/
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Promethazine/Phenergan
• • •
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Lot # & Exp. Date
/
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Metronidazole/Flagyl
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Lot # & Exp. Date
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T-Relief Topical Pain Relieving Ointment
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Lot # & Exp. Date
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Ondansetron-Zofran
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Lot # & Exp. Date
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Azithromycin
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Lot # & Exp. Date
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Levonorgestrel-Plan B
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Lot # & Exp. Date
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Bacitracin/neomycin/polymyxinB topical Ointment
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Lot # & Exp. Date
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Ceftriaxone
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Lot # & Exp. Date
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Doxycycline
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Lot # & Exp. Date
/
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Diphenhydramine-Benadryl
• • •
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Lidocaine hydrochloride 1% Injectable
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Lot # & Exp. Date
/
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0.9% sodium chloride injection
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Lot # & Exp. Date
/
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Ibuprofen
• • •
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Lot # & Exp. Date
/
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Comments for medications not given:
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SANE Progress Notes
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SANE Progress Notes
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Body Diagrams
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Gender Neutral
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Gender Neutral Facial/Head Front & Back
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Gender Neutral Facial/Head Font & Back: (Comments)
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Gender Neutral Face & Neck Lateral
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Gender Neutral Face & Neck Lateral: (Comments)
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Gender Neutral Anterior Neck
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Gender Neutral Anterior Neck: (Comments)
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Eye Diagrams
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Eye Diagram Forward-Downward-Upward
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Eyes: (Comments)
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Eye Diagram Side-to-Side
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Eyes: (Comments)
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Female Diagrams
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Female Face (Front & Lateral)
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Female Face (Front/Lateral): Comments
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Female Body (Front & Back)
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Female Body (Front & Back): Comments
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Female Body (Lateral)
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Female Body (Lateral): Comments
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Breasts
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Breasts: Additional Comments
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Male Diagrams
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Male Face (Front & Back)
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Male Face (Front & Back): Comments
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Male Face (Lateral)
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Male Face (Lateral): Additional Comments
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Male Body (Front & Back)
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Male Body (Front & Back): Comments
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Male Body (Lateral)
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Male Body (Lateral): Additional Comments
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General Diagrams
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Mouth
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Mouth: Additional Comments
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Hands
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Hands: Additional Comments
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Feet
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Feet: Additional Comments
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