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Safety alert:
Computer use can be monitored and is impossible to completely
clear. If you are in danger, please use a safer computer, call
your local hotline at 1-800-472-2911, and/or call the National
Domestic Violence Hotline at
1-800-799-SAFE. If you are at a safer computer, click
here to read more. |
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For a hard copy of the protocol
please contact NDCAWS at 1-888-255-6240. |
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Sexual Assault Evidence Collection Protocol |
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Return to
Evidence Collection Protocol Index |
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DISCHARGE
SUMMARY
During your visit we have discussed the following:
PREGNANCY
You were tested for pregnancy: Yes___ No___
(Because:____________________
__________________________________________________________________)
Your pregnancy test was: Positive___ Negative___ Testing not
indicated___
You were given Plan B (levonorgestrel) as emergency
contraception to prevent
pregnancy. Take 1 tablet now and 1 tablet in 12 hours by
mouth.
SEXUALLY TRANSMITTED DISEASES
1. You were given______________________ and__________________
as
treatment to prevent chlamydia and gonorrhea.
2. Any other treatments or tests done in the ER
today:______________________
___________________________________________________________________
3. It is highly recommended you have a medical follow-up in
7-14 days for a
pregnancy test, STD testing, and to discuss HIV testing. See
the Suggested
Follow-Up Appointments sheet.
SAFETY
Discharge
to:________________________________________________________
___________________________________________________________________
FOLLOW-UP PHONE CALL
Your phone number is______________ . Can we call you at this
number and
leave a message? Y___ N___. Any special instructions for
calling you?________
___________________________________________________________________
I will call you on ____________ to see if you need assistance
making a follow-
up appointment or have any questions. If you need to speak
with me before then, call the Emergency Center at 234-5121 and
leave a message and I will call you back.
COUNSELING
It is recommended that you follow-up with the Rape and Abuse
Crisis Center for
counseling. An advocate is available 24 hours a day to speak
with you. Call 293-7273.
___________________________
______________________
Sexual Assault Nurse Examiner
Client
page 1 of
2 |
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Used with
permission of Meritcare Hospital, Fargo. |
