M F. Interpreter Name

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1 PATIENT INFORMATION D L V Name Gender M F Age Time Date HMC# Street Address Apt. Phone City State Zip OK to call with msg? Yes No Police Report Made Yes No Accompanied by Contact Person Relationship Relationship Police Department Case # Phone CPS Report Yes No Interpreter Yes 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. Signature of patient (or legal guardian) Relationship (guardian) Date Patient is a year old minor and demonstrates a level of understanding and maturity consistent with ability to sign for examination and treatment. AUTHORIZATION FOR RELEASE OF INFORMATION Witness Date Harborview Medical Center Consent for Release of Medical Information signed by Patient Other EVIDENCE TRANSFER I hereby certify that I have received from at Harborview Medical Center the following items: Dept: Officer: Phone: Case # Date/Time DISCHARGE PLAN Discharged To: Home Other: Phone (if different from above): Patient Education and Community Resource Materials given Follow-up Appointment HCSATS Date Time Other: Date Time Name (print) Signature Discharge time Date PAGE 1 OF 6

2 SOCIAL WORK EVALUATION Informant(s): Patient Other: Current concerns Brief history (Include pt. quotes as appropriate) Appearance, Emotional state Reporting plans For children: List sources of information Who present at interviews If child interviewed, attach nearverbatim record Who child resides with CPS or custody issues Other children at risk Date of Assault Site of assault Own home Other home Unknown Vehicle Outdoors Other Time of Assault Hours Since Assault #Assailants #Sexual Assailants Relationship of Assailant/s Patient knew assailant: <24 h >24 h Use of Verbal Threats Use of Physical Force Use of Weapon Interested in counseling? Yes Maybe No Perceived Life Threat Prior Trauma Hx Prior or Current Mental Health Hx Social support for this event? Age of Assailant Child Teen (13-17) Adult Unknown Specify Discussed: Stress reactions Yes No Coping/fear reduction Yes No Intervention/Services Yes No Medical f/u Yes No Personal safety plan Yes No Specify: TIME SPENT with patient/family minutes SW name (print) Signature Date PAGE 2 OF 6

3 CURRENT MEDICAL HISTORY ASSAULT HISTORY Yes Unk/ Unsure FORCE Threat to harm Restrained Hit kicked thrown Choked / strangled Bitten (human bite) Abuse of authority / Peer stress /Unable to resist Other force: IMPAIRMENT Impaired consciousness at onset of assault Asleep Substance Amnesia for assault event Total Partial Recent voluntary substance use: type/amt No Informant Time since assault Patient Other hrs Additional assault history, explanation of positives, patient quotes Suspicion of surreptitious drug Forced drug ingestion TYPE OF CONTACT (by assailant to patient) Penis to Vagina Anus Mouth Other: Hand to Vagina Anus Penis Other: Mouth to Vagina Anus Penis Other: Foreign object/other contact: Condom used? Ejaculation? Site CURRENT CONCERNS See progress record for continuation ASSAILANT RISK FACTORS document in all cases UNKNOWN POST-ASSAULT Known HIV pos Known IV drug use Assailant is man who has sex with men None Bathe / shower Douche Urinate Defecate Rinse mouth / brush teeth Eat Drink Bring clothes? Change clothes? Give clothes to police? REVIEW OF SYSTEMS Check negatives, circle positives, explain SKIN: injury/pain MUSCULOSK: injury/pain NEURO: headache, weakness, loss of consciousness HEENT: neck/throat pain difficulty swallowing RESP: difficulty breathing at assault/ now CARDIAC: chest pain GI: nausea/ vomiting Abd pain GU: vaginal or rectal pain vaginal or rectal bleeding (circle) ALLERGIES: see p. 6 PSYCH: see p. 5 Examiner Name (print) Signature Date PAGE 3 OF 6

4 PAST MEDICAL HISTORY / EXAM Last menstrual period No menarche Current contraception OC s: Missed pills? Condoms Depo-Provera: Last dose Other method: No contraception Last consensual intercourse hrs days >14 days No prior intercourse GYN history Gravida Para Other medical-surgical history, hospitalizations, chronic illness Psych/Trauma history PMD Clinic Current medications PHYSICAL EXAM General description of patient (demeanor, mood, posture, state of dress, emotional state during exam, etc.): GENERAL Vital signs: BP HR RR T PELVIC / GENITAL EXAM Speculum used? Yes No Skin See traumagram Vulva Scrotum HEENT Posterior fourchette/fossa Neck Chest Hymen Heart Vagina Penis Abd Perineum Extremities Anus Neuro/Mental status Bimanual exam No bimanual exam Examiner name (print) Examiner signature Date PAGE 4 OF 6

5 TRAUMAGRAM / LABS A = Abrasion B = Bite C = Contusion / bruise (indicate color/size) L = Laceration (indicate size) INJURIES R = Redness S = Swelling T = Tenderness SS = Skin swab locations PHOTOS Taken by Photo of label taken No photos Body Colposcopy Magnified genital OTHER Examiner name (print) Signature Date PAGE 5 OF 6

6 ASSESSMENT / PLAN ASSESSMENT 1. (History, concern, report of sexual assault) 2. (Acute physical findings) 3. (Other findings / medical conditions) 4. (Other findings, / medical conditions) I request that emergency contraception ( morning after pill ) be given to me and understand that it is 75% effective in preventing pregnancy if taken within 72 hours. Information about how this medicine works has been explained to me and my questions, if any, have been answered. Attending MD Note (sign ED front sheet also) Medical-Surgical eval Urine Beta HCG Lot (females 11-55) Results Blood alcohol Toxicology Bedside Hospital lab STD testing as indicated Urine GC/Chlamydia Other Results Results HCSATS outreach call Follow-up medical appointment Other: PLAN Evidence Clothing bags Forensic urine specimen (in freezer) Photos Other Evidence kit Trace evidence Skin debris Underpants Pubic hair Oral swabs combing Fingertip Pubic hair swabs plucking Head hair Perineal/vulvar plucking Vaginal/cervix Skin swabs Perianal/anal Sites Reference blood Other Discharge Instructions given NO EVIDENCE COLLECTED MEDICATION ALLERGIES No known drug allergies HEPATITIS B Completed vacc s # History Hep B None / Unknown MEDICATIONS NO MEDICATIONS GIVEN Indication Medication / Dose Route Time Initials Chlamydia prophylaxis Azithromycin 1 gm PO Signature Notes / Protocol Deviation/ LAB DONE - results Gonorrhea prophylaxis Emergency contraception (2 tabs at once) Hepatitis B Vaccine lot/exp/site Cefixime 400 mg po <OR> Cefpodoxime (Vantin) 400 mg <OR> Ceftriaxone 125 mg <OR> Ciprofloxacin 500 mg Severe Pen allergy only Levonorgestral 0.75 mg x 2 Hep B Vac. 1.0 ml Vaccine info sheet date PO IM PO PO IM (deltoid) Open wound (s) No tetanus vaccine >5 yr Td Vac 0.5 ml Vaccine info sheet date IM Time spent w/ patient and family Other medications: Exam done in ED Inpatient: Other: Prescribing MD Name Signature Date Evidence packaged by SANE <OR> RN Signature Date Exam performed by SANE <OR> MD Signature Date / Discharge Time PAGE 6 OF 6