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. |

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|____ 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 |

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|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 _____ | |

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| |PMD ______________________________ Clinic _________________ |

|Psych/Trauma history |Current medications |

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|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] | |

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| | |[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 | | |

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| |Gonorrhea prophylaxis |ο Ceftriaxone 250 mg | | | |

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| | | |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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