ABC Template

OVERALL_INSTRUCTIONS

Chief Complaint

This is a [Patient age] female who is brought to ABC House today for evaluation of possible: [List all applicable concerns] (Select from: abnormal anogenital finding previously observed by examiner / sexual abuse / physical abuse / neglect / medical neglect / exposure to domestic violence / exposure to methamphetamine manufacturing / parental substance use / caretaker substance abuse and drug endangered environment / problematic sexual behavior).

Template

Dear Dr. [Last Name], DATE OF EVALUATION: [Date of evaluation] DATE OF FORENSIC INTERVIEW: [Date of forensic interview or N/A] PATIENT ACCOUNT NUMBER: [Patient account number] PATIENT NAME: [Patient full name] DOB: [MM/DD/YYYY] AGE: [Patient age] EXAMINING MEDICAL PROVIDER: [Name of Provider] (Select: Dr. Karen Gray DNP, CPNP-AC / Dr. Carol Chervenak, MD / Barba Beatty, CPNP) ATTENDANT: [Name of Attendant] (Select: Alyssa Critchfield, CMA / none / not applicable) ACCOMPANYING THE PATIENT: [Guardian Name] Relationship: [Relationship to patient] In addition to this Examining Medical Provider; [Name of Provider], the following were present for the review today: \n ODHS: [DHS Worker Name], [County] (Select: Linn County / Benton County) \n FORENSIC INTERVIEWER: [Interviewer Name] (Select: Heather Perez / Katelynn Weisner / Amanda Patterson / N/A) \n LEA: [Rank and Name of Agent] [Agency] (Select: Albany Police Department / Benton County Sheriff's Office / Corvallis Police Department / Lebanon Police Department / Linn County Sheriff's Office / Oregon State Police / Philomath Police Department / Sweet Home Police Department) \n OTHER: [Specify other individuals present or N/A] CHIEF COMPLAINT: This is a [Patient age] female who is brought to ABC House today for evaluation of possible: [List all applicable concerns] (Select from: abnormal anogenital finding previously observed by examiner / sexual abuse / physical abuse / neglect / medical neglect / exposure to domestic violence / exposure to methamphetamine manufacturing / parental substance use / caretaker substance abuse and drug endangered environment / problematic sexual behavior). HISTORY OF ALLEGATION: The ABC House personnel were contacted about the above concern by [Name and Agency]. *The information below may include a summary of outside reports. For further details please refer to the individual reports referenced. The following reports are reviewed: 1. DHS Screening Report: Screening Report: [Report Number] Dated: [MM/DD/YYYY] (Summarize reported history from uploaded 307 form. Do not include any recorded verbal history from today's evaluation) 2. Law Enforcement: [Name of Agency] Case Report: [Case Number] Dated: [MM/DD/YYYY] (Summarize reported history from uploaded Law enforcement case reports. Do not include any recorded verbal history from today's evaluation) 3. ABC House medical records for [Patient or Sibling Name] DOB: [MM/DD/YYYY] -patient account # [Account Number] Dated: [MM/DD/YYYY] [Type of encounter]. (Summarize encounter from uploaded previous ABC House medical records. Do not include any recorded verbal history from today's evaluation) Samaritan Health Services Medical records for [Patient Full Name] [DOB] are reviewed. Verbal Report: [Name of Agency], [Name of Agency Worker] reports, (Document verbally recorded history of allegation as provided by DHS and law enforcement) HISTORY FROM PARENT: Indications for the comprehensive medical examination and necessary testing were explained, and consent was obtained with: [Name of person giving consent] Current concerns and medical history are privately reviewed with [Names of those present during history review] (Include their role: DHS worker, Officer, medical student etc. Do not include the examining medical provider or the patient’s guardian) with the consent of the [Name of historian and relationship]. What are you most concerned about regarding [Patient First Name] today? "[Verbatim response]" Briefly tell me what the circumstances are that brought you and [Patient First Name] to the ABC House today: "[Verbatim response]" What does [Patient First Name] know about today's exam? "[Verbatim response]" Have you talked about what's going on with them? (Yes/No) "[Verbatim response regarding what historian and patient have said]" PATIENT PAST MEDICAL HISTORY: History Provided By: [Name of historian and relationship], the patient, and review of medical records. BIRTH HISTORY: Prenatal care: [Unknown / Yes / No] (If yes, provide details) Maternal pap smear: [Unknown / Yes / No] (If yes, provide details) Prenatal drug/alcohol exposure: [Unknown / Yes / No] (If yes, specify substances and details) Delivery details: [Normal spontaneous vaginal delivery / C-section / Unknown / Other] (Provide details) Gestational age: [Weeks / Unknown] Birth weight: [Weight / Unknown] Pregnancy/delivery complications: [List complications] (Select: unknown / fetal distress and details / gestational diabetes / inadequate prenatal care / infection and details / preeclampsia / GBS positive: treated / GBS positive: untreated / prolonged rupture membranes / nuchal cord / meconium aspiration / meconium staining / maternal STDs: list) NICU stay: [Unknown / Yes / No] (If yes, provide duration) Discharge details: [Describe / Unknown] IMMUNIZATIONS: (If up to date: "Vaccinations are up to date as recorded in Oregon VISS." If unknown: "unknown.") ALLERGIES: (List allergies or "No known drug allergies") CURRENT MEDICATIONS: (List medications from uploaded file 'medications' and any additional provided by historian. Include name and dose) OB/GYN HISTORY: (Include only if mentioned, remove if not) Patient is [premenarchal / menarchal]. (If menarchal, Age of onset: [Age]) Last Menstrual Period: [Date] Details of menses: Menses is [regular / irregular]. Frequency and duration: [Frequency and duration]. [Has heavy bleeding / Does not have heavy bleeding], [Has painful menses / Does not have painful menses], She [does use tampons / does not use tampons]. Previous pelvic examination: [Yes / No] (If yes, when: [Date], and if she had pain with exam: [Details]) RECENT/ACUTE ILLNESS/INJURY: (List illnesses/injuries in past 2 weeks with dates. If unknown, input "unknown.") GENERAL HEALTH: (Select: "The child’s general health is good with typical childhood illnesses" OR "Child has a complex medical history") (List emergency department visits since birth where chief complaint was injury or UTI with dates and diagnoses) (List well child visits with dates) MEDICAL HISTORY: (List any history not in problems list. If unknown, input "unknown") PROBLEMS LIST: (List identified active medical problems with dates. If unknown, input "unknown") SURGERIES/HOSPITAL ADMISSIONS: [Unknown / No / Yes] (If yes, list surgeries/admissions with dates) PROVIDERS: Mental Health Specialist: [Unknown / Yes / No] (If yes, provide details) Primary Care Provider: [Unknown / No / Yes] (If yes, provide name) Date of Last Well-Child Visit: [Date / Unknown] Dentist: [Unknown / No / Yes] (If yes, provide name) Date of Last Dental Visit: [Date / Unknown] DEVELOPMENTAL HISTORY: Patient is [delayed / not delayed]. (Insert dot phrase details) SCHOOL PERFORMANCE/DAYCARE: (Include only if mentioned) Attends Daycare: [Yes / No / Unknown] (If Yes, provide name and details) Attends School: [Yes / No] (If Yes, include Name and details) Academic Performance: [Above average / Average / Below average / Unknown] Attendance: [Good / Fair / Poor / Unknown] Suspension & Expulsions: [Yes / No / Unknown] (If Yes, provide details) IEP/ 504 Plan: [Yes / No / Unknown] Difficulties getting along with other children? [Yes / No / Unknown] (If Yes, provide details) REVIEW OF SYMPTOMS: Constitutional Symptoms: Child has [no known recent history accidental ingestion, constitutional symptoms such as fever, headache, nausea, dizziness, nausea and vomiting, sleep problems / recent history of and describe constitutional symptoms]. Head: Child has [no known recent history of head injury / has recent history of head injury and describe]. Eyes: Child has [no known recent history of eye injury, eye infection or vision problems / recent history of and describe eye symptoms]. Ears: Child has [no history of known hearing loss, or recent infections / history of recent and describe ear symptoms]. Nose: Child has [no known recent history of trauma, or epistaxis / recent history of and describe nose symptoms]. Mouth: Child has [no known recent history of dental injury, dental infection, dental caries, mouth/tooth pain, or bleeding gums / recent history of and describe mouth symptoms]. Neck/Throat: Child has [no known recent history of injury, infections, or lymphadenopathy / recent history of and describe neck and throat symptoms]. Cardiovascular: Child has [no known recent history of chest pain, injury, palpitations, or murmurs / recent history of and describe cardiovascular symptoms]. Respiratory: Child has [no known recent history of breathing difficulties, respiratory symptoms, cough, recent asthma attack, or wheezing / has recent history of and describe respiratory symptoms]. Gastrointestinal: Child has [no known recent history of abdominal pain, blood in stool, constipation, encopresis, GI symptoms, rectal bleeding / recent history of and describe gastrointestinal symptoms]. Genitourinary: Child has [no known recent history of accidental injury to anogenital area, anogenital bleeding, anogenital discharge, blood in urine, dysuria, enuresis, GU symptoms, invasive medical procedures of the anogenital area, urinary incontinence, urinary tract infection / recent history of and describe genitourinary symptoms]. Integumentary: Child has [no recent history of acne problems, cultural practices resulting in skin injury, rash, skin-related symptoms / recent history of and describe integumentary symptoms]. Musculoskeletal: Child has [no recent history of fractures / recent history of fractures and describe recent fractures]. Hematologic/Lymphatic: Child has [no recent history of bleeding problems, easy bruising / recent history of and describe hematologic and lymphatic symptoms]. Allergic/Immunologic: Child has [no recent history of allergic or immunologic symptoms, seasonal allergies / recent history of and describe allergic and immunologic symptoms]. Psychiatric/Behavioral: Child has [no known recent history / recent history of fear of people/place/situations, increase in anger/aggression, sexualized behavior or play, withdrawal from family and/or friends, running away, match or fire play, cruelty to animals, depression, intentional overdose, sleep problems/nightmares, previous abuse evaluation]. FAMILY HISTORY: There is a family history of: [Unknown / Non-contributory / List positive findings] (Select: alcoholism / asthma / ADHD / ADD / bleeding disorder / bone fragility / deafness / diabetes / substance abuse / psychiatric illness / seizures) (Enter details of any positive answers in list format with relationship to the patient) SOCIAL HISTORY: BIOLOGICAL MOTHER: [Name], DOB: [MM/DD/YYYY], Age: [Age] yo BIOLOGICAL FATHER: [Name], DOB: [MM/DD/YYYY], Age: [Age] yo SIBLINGS: [List names, date of birth and ages] PARENTAL PARTNER HISTORY: [Describe] CURRENT HOUSEHOLD MEMBERS: [List] CUSTODY INFORMATION: Custody of this child is with [Describe custody arrangement] RESIDENCY INFORMATION: [Describe] CARETAKERS: The primary caregivers for this child is with [List names and relationships] PRIOR CONCERNS OF ABUSE (CHILD & FAMILY): [No prior concerns of abuse / Reported a family history of abuse and enter details] DISCIPLINE METHODS: [Enter details] DRUG AND ALCOHOL USE IN THE FAMILY: [Enter details] DRUG AND ALCOHOL USE BY THE PATIENT: [Enter details] WEAPONS EXPOSURE: [Enter details] DOMESTIC VIOLENCE EXPOSURE: [Enter details] PORNOGRAPHY OR ADULT SEXUAL ACTIVITY EXPOSURE: [Enter details] ADDITIONAL FAMILY STRESSORS: [Enter details] PRIOR DHS/LAW ENFORCEMENT INVOLVEMENT: [Unknown / No / Yes] (If applicable, input table format: Date | Case Name | Allegation | Disposition | Name of people if founded) ADDITIONAL QUESTIONS/INFORMATION: (Document any additional relevant questions or information verbally reported by historian) FORENSIC INTERVIEW: No forensic interview was conducted. Prior to the examination and medical history taking, a forensic interview was conducted by [Interviewer Name] (Heather Perez / Katlynn Weisner / Amanda Patterson) on [Date]. The interview was [observed / reviewed] by the examiner from the [monitor room / following its completion]. Following completion of the examination and medical history taking, a forensic interview was conducted by [Interviewer Name] (Heather Perez / Katlynn Weisner / Amanda Patterson) on [Date]. The interview was [observed / reviewed] by the examiner from the [monitor room / following its completion]. The following information is a summary of statements [Patient Name] made during the interview and does not represent the totality of the interview. For a complete account, please refer to the recording of the interview on [Date]. (Enter summary of the patient’s responses during the uploaded file transcript titled 'forensic interview' that are positive for physical violence, sexual content, drug exposure, and neglect. Do not use verbal recorded reports) The estimated length of the video recording of the forensic interview was approximately [Value]. PATIENT EXAM AND HISTORY FROM PATIENT PHYSICAL EXAM: Examination status: (Select one) Physical examination is performed in its entirety. Physical examination is deferred. No specific medical indication or current medical concerns identified by parent or caretaker. Physical examination is deferred secondary to patient menses. Physical examination is declined by parents. Physical examination is not completed in its entirety per parent's request. Physical examination is not completed in its entirety per patient's request. Present during the physical exam are the examiner [Name of Provider], [Name of Attendant], [Other medical professional names and title], and the patient [Patient Name]. During the examination [Patient First Name] is: [Describe behavior] VITAL SIGNS: Height: [Value] Weight: [Value] BMI: [Value] for age. Blood pressure sitting: [Value] mmHg Head circumference: [Value] (Percentile for age: [Value]) GENERAL: Patient is a [Patient Age] [Ethnicity] female is in no apparent distress who looks her given age, is well-developed and well nourished. HEENT: Head is [normocephalic and atraumatic / describe abnormal findings]. Eyes are [PERRLA, EOMI, red reflex present, conjunctiva without erythema or hemorrhage, with normal fundoscopic exam / describe abnormal findings]. Tympanic membranes are [clear and mobile bilaterally / describe abnormal findings]. The nares are [clear, turbinates WNL, septum is midline / describe abnormal findings]. Oropharynx is [patent, clear without lesions. No tonsillary hypertrophy. Dentition is normal for age, and frenula is intact / describe abnormal findings]. NECK: [supple without lymphadenopathy or thyromegaly. +FROM / describe abnormal findings]. LUNGS: [CTA, no wheezes, rhales or rhonchi / describe abnormal findings]. CARDIOVASCULAR: [Regular rate and rhythm with normal S1 and normal physiologically split S2. No S3, S4, rubs, murmurs, clicks, gallops, thrills, or heaves. Quiet precordium / describe abnormal findings]. CHEST/BREAST: [Describe findings] ABDOMEN: [soft, non-tender, bowel sounds present x4 without hepatomegaly and splenomegaly / describe abnormal findings]. NEUROMUSCULAR: [Moves all extremities equally. No focal findings. Deep tendon reflexes +2 and equal bilaterally with toes down going / describe abnormal findings]. EXTREMITIES: [Clear, without clubbing, cyanosis, edema or deformity. Capillary refill <3 seconds. Normal sensation / describe abnormal findings]. SKIN: [No rashes, lesions, unusual scars or abnormal bruising / describe abnormal findings]. NEUROLOGICAL/PSYCHIATRIC: [Normal mood, affect, attention span and concentration for age and development. Acting appropriate for age and situation / describe abnormal findings]. GENITALIA: (Choose appropriate response, remove sections that are not appropriate) [Deferred exam / patient refused exam / parent refused exam]. (Insert dot phrase as needed) ANAL: (Choose appropriate response, remove sections that are not appropriate) [Exam is deferred / Patient refused exam / Parent refused exam] (Insert dot phrase as needed) ADDITIONAL COMMENTS: (Choose appropriate response, remove sections that are not appropriate) PATIENT TERMINOLOGY FOR GENITALIA AND BUTTOCKS: [The child's name for the genitals is: "privates" / "private parts" / "pee pee" / "vagina" / "down there" / "no no square" / "thing" / "other" / "penis"]. [The child's name for the buttocks is "[Describe]"]. [The child did not identify a name for her genitals during the examination.] LIGHT SOURCE: [150 watt halogen from the colposcopy unit / full spectrum exam room lights / overhead fluorescent lighting]. MAGNIFICATION: [not applicable / used with the colposcope was 4x, 10x]. PHOTO DOCUMENTATION: [Not applicable / Nikon D3100 14.2-megapixel digital camera with colposcopic magnification / Nikon Z50 digital camera with macrolens for general physical findings]. LABS: Labs collected today: [Yes / No] Labs ordered to be completed outpatient: [Yes / No] Imaging ordered to be completed outpatient: [Yes / No] Patient refused all lab work: [Yes / No] Patient refused but consented to: [Specify] Parent refused all lab work: [Yes / No] Parent refused but consented to: [Specify] Forensic evidence collection for sexual assault was done by protocol: [Yes / No] Gonorrhea and chlamydia nucleic acid testing from anal swab collected during exam: [Yes / No] Gonorrhea and chlamydia nucleic acid testing from oral swab collected during exam: [Yes / No] Gonorrhea and chlamydia nucleic acid testing from vaginal/urethral swab collected during exam: [Yes / No] Gonorrhea and chlamydia testing by Cobas PCR from urine ordered: [Yes / No] SurePath Pap Smear (HPV) of cervix performed during exam: [Yes / No] Trichomonas, candida, and Gardnerella nucleic acid testing from urethral/vaginal swab: [Yes / No] HSV swab for active lesions collected during exam: [Yes / No] Urine collected [bagged] for amphetamine/methamphetamine confirmation testing: [Yes / No] Hair collection (~400 mg) for environmental exposure to illicit substances performed according to USDTL protocol: [Yes / No] (Description of hair color: [Color]) Other labs: [Specify] Imaging: [Specify] HISTORY FROM THE CHILD: With the child and [Name and role of others present] / Alone with the child, I again explained that as a pediatric nurse practitioner, my job is to ensure that she is safe and healthy. I asked [Patient Name] if she knew why she had come in for an exam today. She said: "[Verbatim patient response]" I explained that I often see children who have been hurt or touched in a way that they did not like. I asked [Patient Name] if this has ever happened to her. She said: "[Verbatim patient response]" I asked [Patient Full Name] (Document questions asked by examiner verbatim). She said: (Document patient's recorded verbal responses in quotation marks verbatim in list format. Include the history obtained directly from the patient, including explanations given, patient's understanding of the exam, disclosures about abuse or uncomfortable experiences, history of alcohol, drugs, tobacco/vaping, sexual activity, safe sex practices, tampon use, last menstrual period, and any questions or concerns from the patient) At the conclusion of the examination, [Patient Name] was escorted back to the waiting area to the care of [Person accompanying the patient]. DIAGNOSTIC FINDINGS: Reported history: [ODHS / Law enforcement / Name of medical provider / Name and relationship of person accompanying the patient] have reported [events / results] that raise concerns of: [physical abuse / sexual abuse / neglect / domestic violence exposure / familial substance abuse / methamphetamine manufacturing / exposure to illicit substance] involving this child: (Enter summary from the history of allegation section using information provided by uploaded DHS and law enforcement reports as well as verbal comments made by law enforcement, DHS, and guardian that is suggestive of abuse, neglect, exposure to drugs and alcohol, and exposure to domestic violence) History from the child in today’s evaluation: [Patient Name] reported to the examiner, [Examiner Name and Credentials], that she [has / has not] been [hurt or touched in a way that was uncomfortable / hurt or touched in a way that was uncomfortable other than casual play with similar aged children]. (Enter detailed list format of any disclosures made by the patient during their evaluation and interview that are consistent with abuse, neglect, domestic violence, or drug exposure prefacing with the patient’s full name and the patient's verbal disclosure in quotation marks) General physical exam: [Patient Name] (Insert dot phrase) Anogenital exam: [Patient Name] (Insert dot phrase) *For detailed statements that the child provided during today's evaluation please review sections of this report titled History from the child located under PATIENT EXAM AND HISTORY FROM PATIENT and review the recorded forensic interview. SUMMARY: Based upon the history available today, as well as today's physical evaluation, (Insert dot phrases). (Enter detailed list of any disclosures, statements, information from uploaded written reports or physical findings from the evaluation that were consistent with abuse, neglect, domestic violence exposure, and/or drug exposure and use full names and quotations for verbal responses) PLAN: Custody/Notifications: Pending further evaluation by ODHS and law enforcement, this child will remain the custody of [his/her] [biological mother / biological father / foster parent / maternal grandfather / maternal grandmother / paternal grandfather / paternal grandmother / biological parents / other: [Specify]]. [DHS / Law Enforcement / the patient's primary care provider] [have been / has been / will be] notified regarding this evaluation and the concerns for the child. Recommendations regarding visitation or contact with [alleged parental perpetrator] are deferred to ODHS. I met with [parent/guardian] to discuss the evaluation and recommendations. In addition to this examiner, [Names] were present for the debriefing. Primary Care: It is recommended that children who have been maltreated be evaluated more frequently by their primary care provider. Children who have been maltreated or experienced other adversities may have difficulties in brain development affecting their social emotional milestones, their cognition and academic performance. The child is referred back to her primary care provider for further care and special attention to: [Describe]. Labs/Imaging: Follow up on the following tests and evaluations: No laboratories or imaging orders were obtained today CBC with platelets PT/PTT Tube to hold for Von Willebrand panel Urinalysis UCG Urine drug screen and methamphetamine confirmation Skeletal survey Skeletal survey in 2 weeks Hair collection for environmental exposure to illicit substances performed according to USDTL protocol. GC/Chlamydia urine test by PCR GC/Chlamydia NAAT (PCR) by vaginal, anal, oral swabs VPIII (Trichomonas, Candida, Gardnerella) NAAT by vaginal swab syphilis screen Baseline serology for [HIV Ag/Ab combo, Hepatitis B surface antigen, Hepatitis C, and RPR] Follow-up serology at 4 to 6 weeks, 3 months, 6 months, and 1 year as indicated Other follow-up tests: [Specify] Caregiver Education: Caretaker education was done around: Parental substance abuse treatment is imperative for the successful, safe care and development of this child. Discuss the importance of stopping and abstaining from all illicit drug use in relation to parenting and creating a safe environment. Discuss the impact of marijuana use on parenting and mental health, including safe storage and risks of ingestion by children. Counseling options and resources for the non-offending caretaker were discussed. Discipline strategies were discussed. Review age-appropriate supervision with caretakers. Caretaker education was done around issues of child sexuality, activity and trauma. Discuss the need for more frequent bathing and toothbrushing. Provide patient education on lice and scabies eradication and treatment for the child and family. We have requested for caregivers not to question the child regarding their disclosures. Caretakers are instructed to notify ABC House medical provider if there is reoccurrence of genital bleeding. Caretakers are instructed to notify ABC House medical provider if there is reoccurrence of [Describe]. Additional caretaker education topics: [Specify] Recommendations: (Insert dot phrases) ICD-10 Codes: [List format with descriptor] Billing: Greater than two hours and 15 minutes was spent in the care, counseling and coordination of care for this child; additional time was needed due to the complexity of the situation (99354 and 99355) Sincerely, [Examining Medical Provider Name and Title] www.abchouse.org PO Box 68 Albany, OR 97321 541.926.2203 541.926.1378 (fax)