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DV Consent form
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DV Release of Information
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SANE Chart Number
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SANE Nurse(s)
• • •
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Dispatch Time
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Nurse Arrival Time
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Patient Arrival Time
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Case Start Time
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Discharge Time
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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
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Mode of Arrival
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Patient Accompanied By
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Present During Exam
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Rape Crisis Center Advocate
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Referral Source
• • •
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Ethnicity
• • •
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Language
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Interpreter language
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Person(s) Present During Interview
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CVRC Application Complete?
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CVRC Reference Number
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Police Report
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Police Agency
• • •
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Case number
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Officer Present at Facility
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Responding Officer
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Responding Detective
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Date/Time of Assault
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Location of Assault
• • •
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Address of Assault
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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
• • •
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Allergies
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LMP
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Comments
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Currently Pregnant?
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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?
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Name of Primary Care Provider
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History of Event and Risk Assessment
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Who is the abuser?
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How long have you known the abuser?
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Has the violence increased in frequency/severity over the last year?
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Comments
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Have you been strangled/choked by the abuser in the last year?
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Comments
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Does the abuser abuse alcohol or drugs?
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Comments
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Does the abuser have access to a gun?
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Comments
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Did the abuser recently lose their job?
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Comments
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Has the abuser threatened to kill you?
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Comments
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Have they been stalking you?
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Comments
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Did the patient bite or injure the offender?
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Comments
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Did the patient bite or injure the offender?
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Comments
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Does the offender have any mental illness?
• • •
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Comments
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Social Concerns
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Changes to Living Situation
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Support System
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Legal Issues
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Are there any children living in the home?
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If yes, how many?
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Have the children witnessed any violence?
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Comments
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Are the children being abused?
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If yes, CYFD must be contacted.
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Do you have a safe place to go after the exam?
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Comments
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Suicidal Thoughts
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Suicide Evaluation
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Homicidal Thoughts
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Homicidal Evaluation
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Does your partner?
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Use Physical Abuse?
• • •
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Comments
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Use Coercion or Threats?
• • •
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Comments
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Use Intimidation?
• • •
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Comments
|
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Use Emotional Abuse?
• • •
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Comments
|
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Use Isolation?
• • •
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Comments
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Use Minimizing, Denying, and/or Blaming?
• • •
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Comments
|
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Use Male Privilege?
• • •
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Comments
|
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Use Sexual Abuse?
• • •
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Comments
|
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Use Economic Abuse?
• • •
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Comments
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Use the children?
• • •
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Comments
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Did Offender strangle Patient
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Strangulation Assessment
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Patient Medical History of Events
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Patient Medical History of Events
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Patient Affect/Demeanor
|
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Eye Contact
• • •
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Speech
• • •
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Responsive to Clinician
• • •
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Non-Verbal Expressions/Behaviors
• • •
|
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Appearance
• • •
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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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Height
|
Weight (lbs)
|
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Temperature
|
Pulse
|
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Blood Pressure
/
|
Respiratory Rate
|
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Pain Level
|
Pain Location
|
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Character
|
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General Assessment (yes=WNL, No=ABN)
|
Comments
|
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Neurological Exam (yes=WNL, No=ABN)
|
Comments
|
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Oral Exam (yes=WNL, No=ABN)
|
Comments
|
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Cardiovascular Exam (yes=WNL, No=ABN)
|
Comments
|
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Pulmonary Exam (yes=WNL, No=ABN)
|
Comments
|
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Abdomen Exam (yes=WNL, No=ABN)
|
Comments
|
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Muscular/Skeletal (yes=WNL, No=ABN)
|
Comments
|
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Skin Exam (yes=WNL, No=ABN)
|
Comments
|
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Urine Dip
|
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Specific Gravity
|
Nitrites
|
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Glucose
|
Bilirubin
|
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Ketones
|
Leukocytes
|
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Blood
|
pH
|
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Protein
|
Urobilinogen
|
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Urine HCG
|
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Urine HCG
|
Lot # & Exp. Date
/
|
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Body Map
|
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Body map
|
Body Map - Physical Exam/Assessment (Lacerations, Tenderness, Redness, Abrasion, Bruising, Swelling, & Evidence of Past Injury)
|
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Photos of body?
|
If yes, how many?
|
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Photos of clothing?
|
If yes, how many?
|
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Injuries sustained by patient (check any/all that apply):
• • •
|
Comments
|
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Additional Medical Treatment
|
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Additional Medical Consultation
|
Comments
|
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Physician
|
SANE Referral Form
|
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Additional Reporting
|
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Adult Protective Services Needed?
|
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Caseworker Name & Phone Number
|
Other, Agency/Contact Info
|
|
Comments
|
Location
|
|
Child Protective Services Needed?
|
|
|
Caseworker Name & Phone Number
|
Comments
|
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|
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
|
|
|
Care Plan reviewed with patient?
|
Comments
|
|
Safety Plan reviewed with patient?
|
Comments
|
|
DV Discharge Instruction Page 1
|
DV Discharge Instructions Page 2
|
|
|
|
|
SANE Progress Notes
|
|
|
SANE Progress Notes
|
|
