HSA Report Form- final draft - University of Washington
|\\Name |Gender |Age |Time |Date |
| |ο M ο F ο___________ | | | |
|HMC# |DOB |Street Address |Apt. |
|Phone |City |State |Zip |
| | | | |
| | | | |
|OK to call with msg? ο Yes ο No | | | |
| |Accompanied by |Relationship |
|Police Report Made ο Yes ο No |Contact Person |Relationship |
|Police Department Case # | | |
| |Phone | |
|CPS Report ο Yes ο No |Interpreter ο Yes ο No Language |
| | |
|CPS Office Intake Worker |Interpreter Name |
|CONSENT: EXAMINATION, EVIDENCE COLLECTION, PHOTOGRAPHY, EMERGENCY CONTRACEPTION |
|I hereby consent to a forensic medical examination for evidence of sexual assault. The examination has been explained to me and I understand and agree to collection of|
|(please initial): |
|____ Swabs, blood sample, hair samples for DNA evidence |
|____ Urine to test for alcohol or drugs I have taken, or may have been given |
|____ Photographs of body/facial injuries (for medical documentation and police department, if I report the assault) |
|____ Photographs of genital (private parts) and anal areas (for documentation of injury and review) |
|____ I understand that I may refuse any part of this examination at any time. |
| |
|____ I have been informed that this examination will be eligible for payment by Washington State Crime Victims Compensation and that I may apply for further CVC |
|financial assistance for medical and counseling expenses, loss of wages and job re-training. |
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|Signature of patient (or legal guardian) _____________________________ Relationship (guardian) _________________ Date ____________ |
|ο Patient is a _____ year old minor and demonstrates a level of understanding and maturity| | |
|consistent with ability to sign for examination and treatment. | | |
| |Witness |Date |
|DISCHARGE PLAN |
|Discharged To: ο Home ο Other: ________________________ |Follow-up Appointment |
| | |
|Phone (if different from above): ________________________ |ο HCSATS Appt Date _______________ Time ___________ |
| | |
| |ο Madison Clinic Called: Date _______________ |
| |(206) 744-5155 Time ___________ |
| |Jail Discharge Paperwork |
| |Other |
|ο Patient Education and Community Resource Materials given | |
|Name (print) |Signature |Discharge time |Date |
| |
|Informant(s): ο Patient Other: ____________________________________________________________ |
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|Assault Hx: | |
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|Present at Exam: |
|For Patients 14 days |
| |ο Depo-Provera: Last dose______ ο Contraceptive Implant | |
|ο No menarche | | |
| |ο Other method: ___________________________________ ο No contraception |ο No prior intercourse |
|GYN history |Other medical-surgical history, hospitalizations, chronic illness |
| | |
|Gravida _____ Para _____ | |
| | |
| |PMD ______________________________ Clinic _________________ |
|Psych/Trauma history |Current medications |
| | |
| | |
|Examiner Name (print) |Signature |Date |
|Description of demeanor |
| |
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|GENERAL |PELVIC / GENITAL EXAM |
|ο Vital signs reviewed in EMR |Speculum used? ο Yes ο No |
|Skin ο Warm, dry, no acute injuries |Vulva: ο No acute trauma |
|ο Injuries: |ο Injuries: |
|Head ο Non-Tender, no visible injuries |Posterior fourchette/fossa: ο No acute injuries |
|ο Injuries: |ο Injuries: |
|Ears ο No visible injuries |Hymen: ο No acute trauma ο Redundant |
|ο Injuries: |ο Injuries: |
|Eyes ο Clear without Petechiae/hemorrhage |Vagina: ο Normal rugae, no acute injury |
|ο Injuries: |ο Injuries: |
|Mouth ο Mucosa pink/moist; w/o lesions, frenulum intact |Cervix: ο No acute trauma ο Not visualized |
|ο Injuries: |ο Injuries: |
|Neck ο Supple, full range of motion |Perineum: ο No acute injury |
|ο Injuries: |ο Injuries: |
|Chest ο Clear to auscultation |Scrotum: ο No acute trauma |
|ο Injuries: |ο Injuries: |
|Abdomen ο Soft, non-tender |Penis: ο Circumcised ο Uncircumcised ο No acute injuries |
|ο Injuries: |ο Injuries: |
| |Anus: ο Normal folds ο Good tone ο No acute injuries |
| |ο Injuries: |
|Examiner name (print) |Examiner signature |Date |
|[pic] |[pic] | |
| | | |
| | | |
| | |[pic] |
|[pic] |[pic] |INJURIES |
| | |A = Abrasion |R = Redness |
| | |B = Bite |S = Swelling |
| | |C = Contusion / bruise |T = Tenderness |
| | |(indicate color/size) | |
| | |L = Laceration |SS = Skin swab locations |
| | |(indicate size) | |
| | |PHOTOS |
| | | | |
| | |Taken by _________ |ο Photo of label taken |
| | | |ο Body |
| | |ο No photos | |
| | | |ο Colposcopy |
| | | |Magnified genital |
| | |OTHER |
| | | |
|Examiner name (print) |Signature |Date |
|ASSESSMENT |PLAN |
| | |Evidence |
|______________________________________ |ο Medical-Surgical eval | |
|(History, concern, report of sexual assault) | | |
| |ο Urine Beta HCG Lot ______ | |
| |(females 11-55) Results _______ | |
|______________________________________ | | |
|(Acute physical findings) |Toxicology Results _______ | |
| |Bedside | |
| |Hospital lab | |
|______________________________________ | | |
|(Other findings / medical conditions) |ο STD testing as indicated | |
| |Urine GC/Chlamydia | |
| | | |
|______________________________________ |ο Other | |
|(Other findings, / medical conditions) | | |
| |( HCSATS outreach call | |
| |( Follow-up medical appointment | |
| | | |
| |( Other: _________________________ | |
| | | |
| |ο Discharge Instructions given | |
| | |ο Clothing ____ bags |
| | |ο Forensic urine specimen (in freezer) |
| | |ο Forensic blood for toxicology |
| | |ο Photos |
| | |Evidence kit |
| | |ο Trace evidence |ο Skin debris |
| | |ο Underpants |ο Pubic hair combing |
| | |ο Oral swabs |ο Perineal/vulvar |
| | |ο Fingertip swabs |ο Vaginal/cervix |
| | |ο Skin swabs |ο Perianal/anal |
| | |Sites _______ |ο Reference blood |
| | | |ο Control |
| | |ο Other | |
| | | |
| | |ο NO EVIDENCE COLLECTED |
| |MEDICATION ALLERGIES |HEPATITIS B |
|Discussed Case with Dr. _______________________ | | |
| |ο No known drug allergies |ο Completed vacc’s # __ ο History Hep B |
| | | |
| | |ο None / Unknown |
| |Medications ο NO MEDICATIONS GIVEN |
|HIV PEP discussed |Indication |Medication / Dose |Route |Time |Initials |
|Notes / Protocol Deviation/ LAB DONE - results |Chlamydia prophylaxis |ο Azithromycin 1 gm |PO | | |
| | | | | | |
| | | | | | |
| |Gonorrhea prophylaxis |ο Ceftriaxone 250 mg | | | |
| | | | | | |
| | | |IM | | |
| |Trichomonas prophylaxis |Metronidazole 2gm |PO | | |
| |Emergency contraception |ο Levonorgestral |PO | | |
| |Hepatitis B Vaccine |ο Hep B Vac. 1.0 mL |IM | | |
| |lot/exp/site |ο Vaccine info sheet date |(deltoid) | | |
| |HIV prophylaxis |ο Truvada |PO | | |
| | |ο Raltegravir 400mg | | | |
|Time spent w/ patient and family __________ |Tetanus |ο Tdap |IM | | |
| | |ο Td | | | |
| | | | | | |
|Exam done in___ED Inpatient: _______ Other: | | | | | |
| |Other medications: | | | |
|Exam performed by ο SANE ο MD |Signature |Date / Discharge Time |
|Evidence packaged by ο SANE ο RN |Signature | |
|Stangulation Symptom Checklist: |Details of the Strangulation: | |
| Breathing changes or difficulty | One hand | |
|Raspy or hoarse voice |Two hands (Right or Left) | |
|Cough |Forearm (Rigth or Left) | |
|Difficulty/pain when swallowing |Ligature | |
|“ Thick” feeling in throat |Concurrent smothering/suffocation | |
|Cognitive changes (memory |Duration of strangulation | |
|loss/confusion/agitation/difficulty with word |Was patient shaken by neck | |
|finding/restlessness |Was patient suspended by neck (lifted off ground) | |
|Reported LOC or near LOC | | |
|Loss of urine | | |
|Loss of bowels | | |
|Vision changes | | |
|Thought were going to die | | |
|Nausea and /or vomiting | | |
|Scratches/red marks(jaw line, clavicles/neck/behind ears)| | |
|Bruising(jaw line, clavicles/neck/behind ears) | | |
|Bruising and swelling (lips/oral mucosa | | |
|Petechiae(face/neck/inside eye lids/around eyes/behind | | |
|ears) | | |
|Subconjuctival hemorrhage | | |
|Severe pain on gentle palpation of larynx | | |
|If pregnant, # weeks gestation | | |
|cramping | | |
|vaginal bleeding | | |
|Noted Injuries: | | |
| Pt evaluated for strangulation by ED MD prior to SANE| | |
|arrival | | |
|Pt referred back to ED MD for strangulation evaluation | | |
| Strangulation discharge instructions reviewed with pt| | |
|including: | | |
|Stay with someone for 24 hours after strangulation | | |
|event | | |
|Return to ED for | | |
|Difficulty breathing, increased trouble swallowing, | | |
|swelling of neck or throat, increased hoarseness or | | |
|voices changes, blurred vision, severe headaches, | | |
|numbness of arms or legs. | | |
|Examiner name (print) |Examiner signature |Date |
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