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SA Consent form
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SA Release of Information
|
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SANE Nurse(s)
• • •
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SANE Chart number
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Dispatch Time
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Nurse Arrival Time
|
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Patient Arrival Time
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Discharge Time
|
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Case Start Time
|
Case End Time
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Pt address
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Pt City and state
|
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Patient Phone #
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Email Address:
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Follow-Up Contact Requested
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Best Way to Contact
• • •
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Method of Arrival
|
Mode of Arrival
|
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Ethnicity
• • •
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Patient Accompanied By
|
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Rape Crisis Center Advocate
|
Referral Source
• • •
|
|
Person(s) Present During Interview
|
Present During Exam
|
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Language
|
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Interpreter language
|
Comments
|
|
UNM Student/Faculty or Staff?
|
Did the assault occur on UNM campus?
|
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|
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CVRC Application Complete?
|
CVRC Reference Number
|
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Pt in custody
• • •
|
Comments
|
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Police Report
|
Police Agency
• • •
|
|
Police Case Number
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Officer Present at Facility
|
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Responding Officer
|
Responding Detective
|
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Date/Time of Assault
|
Location of Assault
• • •
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Address of Assault
|
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City of Assault
• • •
|
Comments
|
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Past Medical History
|
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Past Medical History or Surgeries
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Current Medications
|
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Self-Disclosed Disabilities
• • •
|
Allergies
|
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LMP
|
Comments
|
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Currently Pregnant?
|
Comments
|
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Vaccinations
• • •
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Vaccine Lot #/ Expiration Date
/
|
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Vaccinations
• • •
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Vaccine Lot #/ Expiration Date
/
|
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Do you have a Primary Care Provider?
|
Name of Primary Care Provider
|
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begin print
|
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Did you have consensual Sex in last 5 days
|
Nature of consensual intercourse:
• • •
|
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How many days ago?
|
Name/Initials of partner:
|
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Suspected DFSA?
|
DFSA Form
|
|
DFSA Symptoms
|
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Genital Symptoms Prior to SA
• • •
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Comments
|
|
|
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Are there any children living in the home?
|
If yes, how many?
|
|
Have the children witnessed any violence?
|
|
|
Are the children being abused?
|
If yes, CYFD must be contacted.
|
|
Do you have a safe place to go after the exam?
|
Comments
|
|
Suicidal Thoughts
|
Suicide Evaluation
|
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Homicidal Thoughts
|
Homicidal Evaluation
|
|
|
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Offender Information
|
|
|
Offender Relationship
• • •
|
Offender Gender
• • •
|
|
Number of Offenders
|
Offender Age(s)
|
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Condom Used
|
Comments
|
|
Lubricant used?
|
Comments
|
|
Use of Weapon
|
Comments
|
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Use of Force
|
Comments
|
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Use of Threat
|
Comments
|
|
|
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Did Offender strangle Patient
|
Concern for Brain injury screen
|
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Strangulation Assessment
|
|
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Breathing
• • •
|
Reported by Patient or Observed by SANE
|
|
Voice
• • •
|
Reported by Patient or Observed by SANE
|
|
Swallowing
• • •
|
Reported by Patient or Observed by SANE
|
|
Behavioral
• • •
|
Reported by Patient or Observed by SANE
|
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Other Symptoms
• • •
|
Reported by Patient or Observed by SANE
|
|
Face
• • •
|
Reported by Patient or Observed by SANE
|
|
Eye/eyelids
• • •
|
Reported by Patient or Observed by SANE
|
|
Nose
• • •
|
Reported by Patient or Observed by SANE
|
|
Ear
• • •
|
Reported by Patient or Observed by SANE
|
|
Mouth
• • •
|
Reported by Patient or Observed by SANE
|
|
Under Chin
• • •
|
Reported by Patient or Observed by SANE
|
|
Chest
• • •
|
Reported by Patient or Observed by SANE
|
|
Shoulders
• • •
|
Reported by Patient or Observed by SANE
|
|
Neck
• • •
|
Reported by Patient or Observed by SANE
|
|
Head
• • •
|
Reported by Patient or Observed by SANE
|
|
Method and Manner of Strangulation
• • •
|
Comments
|
|
For approximately how long?
|
From 1 (low) to 10 (high), how hard was the grip?
|
|
Multiple attempts?
|
Comments
|
|
Multiple methods?
|
Comments
|
|
Assailant's Dominant Hand
• • •
|
|
|
Was patient's head pounded against anything?
|
Comments
|
|
Did the assailant say anything when strangling the patient?
|
What did the patient feel was going to happen?
|
|
Comments
|
|
|
|
|
|
SA Related to Domestic Violence?
|
IPV Assessment not related to SA
|
|
Does your partner use forms of violence?
|
|
|
|
|
|
DV History of Event and Risk Assessment
|
|
|
Who is the abuser?
|
How long have you known the abuser?
|
|
Has the violence increased in frequency/severity over the last year?
|
Comments
|
|
Have you been strangled/choked by the abuser in the last year?
|
Comments
|
|
Does the abuser abuse alcohol or drugs?
|
Comments
|
|
Does the abuser have access to a gun?
|
Comments
|
|
Did the abuser recently lose their job?
|
Comments
|
|
Has the abuser threatened to kill you?
|
Comments
|
|
Have they been stalking you?
|
Comments
|
|
Did the patient bite or injure the offender?
|
Comments
|
|
|
|
|
DV Assessment: Does your partner?
|
|
|
Use Physical Abuse?
• • •
|
Comments
|
|
Use Coercion or Threats?
• • •
|
Comments
|
|
Use Intimidation?
• • •
|
Comments
|
|
Use Emotional Abuse?
• • •
|
Comments
|
|
Use Isolation?
• • •
|
Comments
|
|
Use Minimizing, Denying, and/or Blaming?
• • •
|
Comments
|
|
Use Male Privilege?
• • •
|
Comments
|
|
Use Sexual Abuse?
• • •
|
Comments
|
|
Use Economic Abuse?
• • •
|
Comments
|
|
Use the children?
• • •
|
Comments
|
|
|
|
|
Post-Assault Hygienic Activity
|
|
|
Urinated?
|
Defecated?
|
|
Genital Wash/Wipe?
|
Showered?
|
|
Bathed?
|
Douched?
|
|
Removed/Inserted:
• • •
|
Comments
|
|
Brushed Teeth?
|
Gargled/Mouthwash?
|
|
Vomited?
|
Smoked?
|
|
Eaten?
|
Drank?
|
|
Chewed Gum?
|
|
|
|
|
|
Clothing Information
|
|
|
Clothing Information
|
Description and condition of clothing collected as part of evidentiary exam:
|
|
Photos of clothing?
|
If yes, how many?
|
|
Type of film:
|
Comments
|
|
|
|
|
Patient Medical History of Events
|
|
|
Patient Medical History of Events
|
|
|
|
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Patient Affect/Demeanor
|
|
|
Eye Contact
• • •
|
Speech
• • •
|
|
Responsive to Clinician
• • •
|
Non-Verbal Expressions/Behaviors
• • •
|
|
Appearance
• • •
|
Comments on abnormal appearance
|
|
Additional Comments
|
|
|
|
|
|
Acts Described By Patient
|
|
|
Penetration of Vagina
|
Penis
|
|
|
Finger
|
|
|
Foreign Object
|
|
Comments
|
|
|
Penetration of Anus
|
Penis
|
|
|
Finger
|
|
|
Foreign Object
|
|
Comments
|
|
|
Oral Copulation of Genitals:
|
|
|
Offender to Patient
|
Patient to Offender
|
|
Comments
|
|
|
Oral Copulation of Anus:
|
|
|
Offender to Patient
|
Patient to Offender
|
|
Comments
|
|
|
Masturbation:
|
|
|
Offender to Patient
|
Patient to Offender
|
|
Offender to Self
|
Patient to Self
|
|
Ejaculation:
|
|
|
Did Ejaculation Occur?
• • •
|
|
|
Inside body orifice?
|
Outside body orifice?
|
|
Comments
|
|
|
Additional Acts:
|
|
|
Unwanted touch/contact?
|
Comments
|
|
Offender licked Patient?
|
Comments
|
|
Offender kissed Patient?
|
Comments
|
|
Offender bit Patient?
|
Comments
|
|
Patient bit Offender?
|
Comments
|
|
Offender sucked Patient?
|
Comments
|
|
Did Patient injure Offender?
|
Comments
|
|
Did Offender take photos or video of patient?
|
Comments
|
|
|
|
|
end print
|
|
|
|
|
|
SANE Physical Exam
|
|
|
Height
|
Weight (lbs)
|
|
Temperature
|
Pulse
|
|
Blood Pressure
/
|
Respiratory Rate
|
|
Pain Level
|
Pain Location
|
|
Character
|
|
|
|
|
|
General Assessment (Yes=WNL, No=Abn)
|
Comments
|
|
Neurological Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Oral Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Cardiovascular Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Pulmonary Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Abdomen Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Muscular/Skeletal (Yes=WNL, No=Abn)
|
Comments
|
|
Skin Exam (Yes=WNL, No=Abn)
|
Comments
|
|
Tanner Stage
|
Comments
|
|
|
|
|
Urine Dip
|
|
|
Specific Gravity
|
Nitrites
|
|
Glucose
|
Bilirubin
|
|
Ketones
|
Leukocytes
|
|
Blood
|
pH
|
|
Protein
|
Urobilinogen
|
|
|
|
|
Urine HCG
|
|
|
Urine HCG
|
Lot # & Exp. Date
/
|
|
|
|
|
Body Map
|
|
|
Body map
|
Body Map - Physical Exam/Assessment (Lacerations, Tenderness, Redness, Abrasion, Bruising, Swelling, & Evidence of Past Injury)
|
|
Photos of body?
|
If yes, how many?
|
|
Type of film:
|
|
|
|
|
|
Genital/Anal Examination:
|
|
|
Patient position for examination:
• • •
|
Comments
|
|
Vulva
|
|
|
Mons Pubis (Yes=WNL, No=Abn)
|
Comments
|
|
Labia Majora (Yes=WNL, No=Abn)
|
Comments
|
|
Labia Minora (Yes=WNL, No=Abn)
|
Comments
|
|
Clitoris (Yes=WNL, No=Abn)
|
Comments
|
|
Urethral Meatus (Yes=WNL, No=Abn)
|
Comments
|
|
Anterior Vestibule (Yes=WNL, No=Abn)
|
Comments
|
|
Posterior Vestibule (Yes=WNL, No=Abn)
|
Comments
|
|
Hymen (Yes=WNL, No=Abn)
|
Comments
|
|
Fossa Navicularis (Yes=WNL, No=Abn)
|
Comments
|
|
Posterior Fourchette (Yes=WNL, No=Abn)
|
Comments
|
|
Perineum (Yes=WNL, No=Abn)
|
Comments
|
|
Vagina (Yes=WNL, No=Abn)
|
Comments
|
|
Cervix (Yes=WNL, No=Abn)
|
Comments
|
|
|
|
|
Penis/Scrotum
|
|
|
Penis (Yes=WNL, No=Abn)
|
Comments
|
|
Circumcised?
|
Comments
|
|
Glans (Yes=WNL, No=Abn)
|
Comments
|
|
Urethral Meatus (Yes=WNL, No=Abn)
|
Comments
|
|
Scrotum (Yes=WNL, No=Abn)
|
Comments
|
|
Shaft (Yes=WNL, No=Abn)
|
Comments
|
|
|
|
|
Anal Examination
|
|
|
Buttocks (Yes=WNL, No=Abn)
|
Comments
|
|
Anus (Yes=WNL, No=Abn)
|
Comments
|
|
Anal Rugae (Yes=WNL, No=Abn)
|
Comments
|
|
Anal Tone (Yes=WNL, No=Abn)
|
Comments
|
|
Perineum (Yes=WNL, No=Abn)
|
Comments
|
|
|
|
|
Speculum used?
|
Foley used?
|
|
Toluidine Dye
|
Alternative Light Source (ALS):
|
|
Environmental Debris?
|
Comments
|
|
Fingernail Evidence?
|
Comments
|
|
Miscellaneous Evidence Collected
|
Comments
|
|
Urine or Blood collected?
• • •
|
|
|
|
|
|
Genital Map
|
|
|
Vulva
|
Penis/Scrotum
|
|
Genital Map - Physical Exam/Assessment
|
|
|
Genital photos?
|
If yes, how many?
|
|
Type of film:
|
|
|
|
|
|
Additional Medical Treatment
|
|
|
Additional Medical Consultation
|
Comments
|
|
Physician
|
SANE Referral Form
|
|
|
|
|
Additional Reporting
|
|
|
Adult Protective Services Needed?
|
|
|
Caseworker Name & Phone Number
|
Other, Agency/Contact Info
|
|
Comments
|
Location
|
|
Child Protective Services Needed?
|
|
|
Caseworker Name & Phone Number
|
Comments
|
|
|
|
|
Medication Administration Log
|
|
|
Rocephin/Ceftriaxone
|
Lot # & Exp. Date
/
|
|
Azithromycin/Zithromax
|
Lot # & Exp. Date
/
|
|
Metronidazole/Flagyl
|
Lot # & Exp. Date
/
|
|
Doxycycline
|
Lot # & Exp. Date
/
|
|
Levonorgestrel-Plan B
|
Lot # & Exp. Date
/
|
|
Ella
|
Lot # & Exp. Date
/
|
|
Ondansetron/Zofran
|
Lot # & Exp. Date
/
|
|
Colace
|
Lot # & Exp. Date
/
|
|
Ibuprofen
• • •
|
Lot # & Exp. Date
/
|
|
Acetaminophen
• • •
|
Lot # & Exp. Date
/
|
|
|
|
|
Discharge Instructions
|
|
|
Patient given a 911 phone?
|
Comments
|
|
Safety Plan reviewed with patient?
|
Comments
|
|
NM DPS Statewide Sexual Assault Tracking System Barcode number:
|
SAEK Checklist
|
|
SA Discharge Instruction Page 1
|
SA Discharge Instructions Page 2
|
|
|
|
|
SANE Progress Notes
|
|
|
SANE Progress Notes
|
|
