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Peds SA Consent form
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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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Discharge Time
|
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Case Start 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
|
Mode of Arrival
|
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Child Lives With:
|
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Ethnicity
• • •
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Patient Accompanied By
|
Present During Exam
|
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Rape Crisis Center Advocate
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Referral Source
• • •
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Person(s) Present During Interview
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Language
|
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Interpreter language
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Comments
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Reported to CPS?
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Who reported to CPS?
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Social Worker:
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SW Contact Number
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CVRC Application Complete?
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CVRC Reference Number
|
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CVRC Comments
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Police Report
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Police Agency
• • •
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Police 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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Is child safe in current home?
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Comments
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Is guardian supportive/protective?
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Comments
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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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begin print
|
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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
|
Comments
|
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Currently Pregnant?
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Comments
|
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Do you have a Primary Care Provider?
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Name of Primary Care Provider
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Suspected DFSA?
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DFSA Form
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DFSA Symptoms
|
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Genital Symptoms Prior to SA
• • •
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Comments
|
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Anal Symptoms Prior to SA
• • •
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Comments
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Oral Symptoms Prior to SA
• • •
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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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School/Work Problems
|
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Relationship Problems
|
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Are there other 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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Homocidal Evaluation
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Offender Information
|
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Offender Relationship
• • •
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Offender Gender
• • •
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Number of Offenders
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Offender Age(s)
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Does offender have access to the child?
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Comments
|
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Use of Weapon
|
Comments
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Use of Force
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Comments
|
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Use of Threat
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Comments
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Position of Authority/Coercion
|
Comments
|
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Type of Coercion
• • •
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Comments
|
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Did Offender hurt the child in any other way?
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Strangulation Assessment
|
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Post-Assault Hygienic Activity
|
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Urinated?
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Defecated?
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Genital Wash/Wipe?
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Showered?
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Bathed?
|
Douched?
|
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Removed/Inserted:
• • •
|
Comments
|
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Brushed Teeth?
|
Gargled/Mouthwash?
|
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Vomited?
|
Smoked?
|
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Eaten?
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Drank?
|
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Chewed Gum?
|
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Clothing Information
|
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Clothing Information
|
Description and condition of clothing collected as part of evidentiary exam:
|
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Photos of clothing?
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If yes, how many?
|
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Type of film:
|
Comments
|
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Patient and/or Historian Medical History of Events
|
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Historian 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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Behavioral Changes from Baseline
• • •
|
Comments
|
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Summary of Sexual Acts Described by Patient and/or Historian
|
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Penetration of Vagina:
|
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Penis
|
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Finger
|
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Foreign Object
|
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Disclosed by:
• • •
|
Comments
|
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Penetration of Anus:
|
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Penis
|
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Finger
|
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Foreign Object
|
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Disclosed by:
• • •
|
Comments
|
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Oral Copulation of Genitals:
|
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Offender to Patient
|
Patient to Offender
|
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Disclosed by:
• • •
|
Comments
|
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Oral Copulation of Anus:
|
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Offender to Patient
|
Patient to Offender
|
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Disclosed by:
• • •
|
Comments
|
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Masturbation:
|
|
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Offender to Patient
|
Patient to Offender
|
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Offender to Self
|
Patient to Self
|
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Disclosed by:
• • •
|
Comments
|
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Ejaculation:
|
|
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Inside body orifice?
|
Outside body orifice?
|
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Disclosed by:
• • •
|
Location
|
|
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 child ingest drugs or alcohol?
|
Comments
|
|
Did Offender use lubricant?
|
Comments
|
|
Did child ingest drugs or alcohol?
|
Comments
|
|
Did Offender use a condom?
|
Comments
|
|
Did Offender take photos or video of child?
|
Comments
|
|
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end print
|
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SANE Physical Exam
|
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Time physical is started:
|
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Height
|
Weight (lbs)
|
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Temperature
|
Pulse
|
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Blood Pressure
/
|
|
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Respiratory Rate
|
O2 Saturation
|
|
Pain Level
|
Pain Location
|
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Character
|
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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
|
|
|
|
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Urine Dip
|
|
|
Specific Gravity
|
Nitrites
|
|
Glucose
|
Bilirubin
|
|
Ketones
|
Leukocytes
|
|
Blood
|
pH
|
|
Protein
|
Urobilinogen
|
|
|
|
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Urine HCG
|
|
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Urine HCG
|
Lot # & Exp. Date
/
|
|
|
|
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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
|
|
Exam Techniques:
• • •
|
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
|
|
|
|
|
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
|
|
|
|
|
Colposcope used?
|
Foley used?
|
|
Toluidine Dye
|
Alternative Light Source (ALS):
|
|
Environmental Debris?
|
Comments
|
|
Fingernail Evidence?
|
Comments
|
|
Miscellaneous Evidence Collected
|
Comments
|
|
Urine or Blood collected?
|
DFSA form
|
|
|
|
|
Labs collected per Para Los Ninos (PLN)
|
|
|
Urine GC/CT
|
Swab GC/CT:
• • •
|
|
Other labs
|
Comments
|
|
|
|
|
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
|
|
|
Caseworker Name & Phone Number
|
Other, Agency/Contact Info
|
|
Comments
|
Location
|
|
|
|
|
Medication Administration Log
|
|
|
Levonorgestrel-Plan B
|
Lot # & Exp. Date
/
|
|
Ella
|
Lot # & Exp. Date
/
|
|
Ibuprofen
• • •
|
Lot # & Exp. Date
/
|
|
Acetaminophen
• • •
|
Lot # & Exp. Date
/
|
|
Vaccinations
• • •
|
Vaccine Lot #/ Expiration Date
/
|
|
Vaccinations
• • •
|
Vaccine Lot #/ Expiration Date
/
|
|
|
|
|
Discharge Instructions
|
|
|
Safety Plan reviewed with patient & guardian?
|
Comments
|
|
Care Plan reviewed with patient & guardian?
|
Comments
|
|
NM DPS Statewide Sexual Assault Tracking System Barcode number:
|
SAEK Checklist:
|
|
Peds SA Discharge Instruction Page 1
|
Peds SA Discharge Instructions Page 2
|
|
|
|
|
Services provided:
• • •
|
Comments
|
|
Injuries sustained by patient (check any/all that apply):
• • •
|
Comments
|
|
Referred to:
• • •
|
Comments
|
|
Evidence Collected:
• • •
|
Comments
|
|
|
|
|
SANE Progress Notes
|
|
|
SANE Progress Notes
|
|
|
Information entered into SUDS?
|
|
