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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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Orientee or Student observing exam:
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SANE Chart number
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Type of exam
• • •
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Exam Site Location
• • •
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Location Comments (if offsite, list bedside nurse & provider)
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Dispatch 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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Patient Gender Assigned At Birth:
• • •
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Patient Pronouns (If they want to have in chart)
• • •
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Gender/Sex Assigned At Birth:
• • •
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Comments
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Patient Address
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Patient City and State
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Patient Phone #
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Email Address:
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Parent or other Contact Phone #
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Secondary contact name
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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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Ethnicity
• • •
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Patient Accompanied By
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Advocate
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Referral Source
• • •
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Language
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Comments
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Person(s) Present During Interview
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Present During Exam
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Interpreter language
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Comments
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UNM Student/Faculty or Staff?
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Did the assault occur on UNM campus?
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CVRC Application Complete?
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CVRC Reference Number
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Pt in custody
• • •
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Comments
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Police Report
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Non-reported provider form
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Police Agency
• • •
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Police Case Number
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Responding Officer
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Responding Detective
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Officer Present at Facility
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Date of Assault
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Time of Assault
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Location of Assault
• • •
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Address of Assault
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City of Assault
• • •
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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
• • •
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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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Do you have a Primary Care Provider?
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Name of Primary Care Provider
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begin print
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Did you have consensual sex in last 5 days
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Nature of consensual intercourse:
• • •
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How many days ago?
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Name/Initials of partner:
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Comments about consensual sex
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Suspected DFSA?
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DFSA Symptoms
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DFSA Kit collected?
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DFSA Kit declined?
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APD DFSA Form
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BCSO DFSA Form
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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?
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If yes, how many, their names, and ages?
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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 or use supplemental assessment form
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Homicidal Thoughts
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Homicidal Evaluation
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Comments on suicide or homicide assessments
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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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Comments
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Condom Used
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Comments
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Lubricant used?
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Comments
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Use of Weapon
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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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Domestic Partner/Intimate Partner Violence Screen
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SA Related to Domestic Violence with a current or ex partner?
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IPV Assessment not related to SA
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Does your partner use forms of violence?
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DV Risk Assessment
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Who is the abuser? Give the name.
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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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Have you been strangled/choked by the abuser in the last year?
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Does the abuser abuse alcohol or drugs?
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Does the abuser have access to a gun?
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Did the abuser recently lose their job?
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Has the abuser threatened to kill you?
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Have they been stalking you?
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Does the offender have mental illness?
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Did the patient bite or injure the offender?
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DV Assessment: 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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Reproductive Coercion, Pregnancy questions
• • •
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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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Supplemental Forms
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Did offender strangle patient? Use Strangulation supplemental form.
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Does patent need to be screened for a Traumatic Brain Injury (TBI)? Use HELPS screening supplemental form.
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Does patient need to be screened for Human Trafficking? Use Human Trafficking Screen supplemental form.
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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?
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Douched?
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Removed/Inserted:
• • •
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Comments
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Brushed Teeth?
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Gargled/Mouthwash?
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Vomited?
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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
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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:
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Comments
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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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Acts Described By Patient
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Issues with Disclosure
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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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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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Comments
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Oral Copulation of Genitals:
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Offender to Patient
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Patient to Offender
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Comments
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Oral Copulation of Anus:
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Offender to Patient
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Patient to Offender
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Comments
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Hand on genital contact:
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Offender to Patient
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Patient to Offender
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Offender to Self
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Patient to Self
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Comments
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Ejaculation:
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Did Ejaculation Occur?
• • •
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Inside body orifice?
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Outside body orifice?
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Comments
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Additional Acts:
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Unwanted touch/contact?
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Comments
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Offender licked Patient?
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Comments
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Offender kissed Patient?
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Comments
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Offender bit Patient?
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Comments
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Patient bit Offender?
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Comments
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Offender sucked Patient?
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Comments
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Did Patient injure Offender?
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Comments
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Did Offender take photos or video of patient?
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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
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Weight (lbs)
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Temperature
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Pulse
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Blood Pressure
/
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Respiratory Rate
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O2 Saturation
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Pain Level
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Pain Location
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Character
• • •
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General Assessment (Yes=WNL, No=Abn)
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Comments
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Neurological Exam (Yes=WNL, No=Abn)
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Comments
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Oral Exam (Yes=WNL, No=Abn)
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Comments
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Cardiovascular Exam (Yes=WNL, No=Abn)
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Comments
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Pulmonary Exam (Yes=WNL, No=Abn)
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Comments
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Abdomen Exam (Yes=WNL, No=Abn)
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Comments
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Muscular/Skeletal (Yes=WNL, No=Abn)
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Comments
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Skin Exam (Yes=WNL, No=Abn)
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Comments
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Tanner Stage
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Comments
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Urine Dip
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Glucose
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pH
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Bilirubin
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Protein
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Ketones
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Urobilinogen
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Specific Gravity
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Nitrites
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Blood
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Leukocytes
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Urine HCG
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Lot # and Expiration date
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Body Map
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Body map
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Body Map - Physical Exam/Assessment (Lacerations, Tenderness, Redness, Abrasion, Bruising, Swelling, & Evidence of Past Injury)
|
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Photos of body?
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If yes, how many?
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Type of film:
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Genital/Anal Examination:
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Patient position for examination:
• • •
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Comments
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Vulva
|
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Mons Pubis (Yes=WNL, No=Abn)
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Comments
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Labia Majora (Yes=WNL, No=Abn)
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Comments
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Labia Minora (Yes=WNL, No=Abn)
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Comments
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Clitoris (Yes=WNL, No=Abn)
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Comments
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Urethral Meatus (Yes=WNL, No=Abn)
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Comments
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Anterior Vestibule (Yes=WNL, No=Abn)
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Comments
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Posterior Vestibule (Yes=WNL, No=Abn)
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Comments
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Hymen (Yes=WNL, No=Abn)
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Comments
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Fossa Navicularis (Yes=WNL, No=Abn)
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Comments
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Posterior Fourchette (Yes=WNL, No=Abn)
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Comments
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Perineum (Yes=WNL, No=Abn)
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Comments
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Vagina (Yes=WNL, No=Abn)
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Comments
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Cervix:
• • •
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Comments
|
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Penis/Scrotum
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Penis (Yes=WNL, No=Abn)
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Comments
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Circumcised?
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Comments
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Glans (Yes=WNL, No=Abn)
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Comments
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Urethral Meatus (Yes=WNL, No=Abn)
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Comments
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Scrotum (Yes=WNL, No=Abn)
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Comments
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Shaft (Yes=WNL, No=Abn)
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Comments
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Anal Examination
|
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Buttocks (Yes=WNL, No=Abn)
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Comments
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Anus (Yes=WNL, No=Abn)
|
Comments
|
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Anal Rugae (Yes=WNL, No=Abn)
|
Comments
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Anal Tone (Yes=WNL, No=Abn)
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Comments
|
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Perineum (Yes=WNL, No=Abn)
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Comments
|
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Speculum used?
|
Foley used?
|
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Toluidine Dye
|
Alternative Light Source (ALS) used?
|
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Environmental Debris?
|
Comments
|
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Fingernail Evidence?
|
Comments
|
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Miscellaneous Evidence Collected
|
Comments
|
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Urine or Blood collected?
• • •
|
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Genital Map
|
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Vulva
|
Penis/Scrotum
|
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Genital assessment comments
|
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Genital photos?
|
If yes, how many?
|
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Type of film:
|
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Additional Medical Treatment
|
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Additional Medical Consultation
|
SANE Referral Form
|
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Physician
|
Comments
|
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Additional Reporting
|
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Child Protective Services Needed?
|
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Caseworker Name & Phone Number
|
Comments
|
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Medication Log
|
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Patient declines medications for STI prophylaxis?
|
Patient declines Emergency Contraception medications?
|
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Rocephin/Ceftriaxone
|
Lot and Expiration Date#
|
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Azithromycin/Zithromax
|
Lot and Expiration Date#
|
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Metronidazole/Flagyl
|
Lot and Expiration Date#
|
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Doxycycline
|
Lot and Expiration Date#
|
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Diflucan/Fluconazole
|
Lot and Exp date
|
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Levonorgestrel-Plan B
|
Lot and Expiration Date#
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Ella
|
Lot and Expiration Date#
|
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Ondansetron/Zofran
|
Lot and Expiration Date#
|
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Colace
|
Lot and Expiration Date#
|
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Ibuprofen
• • •
|
Lot and Expiration Date#
|
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Acetaminophen
• • •
|
Lot and Expiration Date#
|
|
Aspirin
• • •
|
Lot and Expiration Date#
|
|
Benadryl
• • •
|
Lot and Expiration Date#
|
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Immunizations
• • •
|
Lot and Expiration Date#
|
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Discharge Instructions
|
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|
Was patient referred to NM Department of Health (NMDoH) or somewhere for nPep?
|
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Women's health care options
|
DFSA testing sites
|
|
Patient given a 911 phone?
|
Right Eye results
• • •
|
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Safety Plan reviewed with patient?
|
Comments
|
|
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NM DPS Statewide Sexual Assault Tracking System Barcode number:
|
SAEK Checklist
|
|
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SA Discharge Instruction Page 1
|
SA Discharge Instructions Page 2
|
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Dear Doctor Letter Page 1
|
Dear Doctor Letter Page 2
|
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SANE Progress Notes
|
|
