ABUSE/NEGLECT/EXPOSURE ALLEGATION

Interview/Exam Abuse/Neglect/Exposure Allegation

Date of Evaluation: [Enter date of evaluation] Patient account number: [Enter patient account number] Patient name: [Enter patient name] DOB: [Enter date of birth] Age: [Enter age] Alleged perpetrator: Name: [Enter alleged perpetrator name] DOB: [Enter DOB] Association to patient: [Describe relationship] Age: [Enter age] Accompanying patient: Name: [Enter accompanying person's name] Relationship: [Enter relationship] In addition to this DMP; [Examiner name and credentials], the following were present for the review today: ODHS Interviewer: [Enter name] LEA: [Enter name] Other: [Specify if applicable]

Chief Complaint

[Describe the reason for referral or evaluation, including who brought the patient and the concerns being evaluated such as physical abuse, neglect, exposure to illicit substances, domestic violence, or other concerns.]

History of the Allegation

[Document the source of the referral or concern, any reports reviewed or not reviewed, and relevant questions such as last time with/around alleged perpetrator, behavioral or emotional changes, and any problems with urination or defecation.]

Patient Past Medical History

Birth History: Prenatal care: [Yes/No and details] Maternal pap smear: [Yes/No and details] Prenatal drug/alcohol exposure: [Specify substances and details] Delivery details: Gestational age: [Enter weeks] Birth weight: [Enter weight] Pregnancy/delivery complications: [Describe] NICU stay: [Yes/No and duration] Discharge details: [Describe]

Parental/Guardian Pre-Exam/Pre-Interview

Indications for the comprehensive medical examination and necessary testing were explained, and consent was obtained with: [Specify who gave consent] History Provided By: [Name] Current concerns and medical history are privately reviewed with the above professionals with the consent of the historian. Questions to address: - What are you most concerned about regarding the patient today? - What does [patient name] know about today's exam? - Have you talked about what's going on with them? If yes, what have you said? What have they said? - What made you think/how did you find out that [patient name] has/had been abused?

Patient Medical History

Patient Medical History: [Provide detailed medical history] Immunizations: [Up to date/Details] Allergies: [List allergies] Current Medications: [List medications] Hospitalizations/surgeries: [List with dates] Medical/Behavioral/Psych Diagnoses: [List] Recent/acute illness/injury: [Describe] Current health concerns: [Describe] Specialist(s): [List] Primary Care Provider (PCP): [Name] Last well-child visit: [Date] Dentist: [Name] Last dental check-up: [Date]

Review of Systems

[For each system below, document positive and negative findings. Use 'negative' if no issues.] - Constitutional: [e.g., weight loss, appetite changes, fevers] - Head: [e.g., headaches, recent injury] - Eyes: [e.g., vision problems, eye injury] - Ears: [e.g., hearing loss, infections] - Nose: [e.g., allergies, epistaxis] - Mouth: [e.g., caries, bleeding gums] - Neck/throat: [e.g., infections, lymphadenopathy] - Cardiovascular: [e.g., palpitations, murmurs] - Respiratory: [e.g., wheezing, cough] - Gastrointestinal: [e.g., pain, vomiting] - Genitourinary: [e.g., hematuria, discharge] - Musculoskeletal: [e.g., fractures, joint pain] - Skin: [e.g., rashes, bruising] - Hematologic: [e.g., bleeding issues] - Psychiatric/Behavioral: [e.g., anxiety, depression, aggression]

OB/GYN History

Premenarchal status: [Yes/No] Menarche began at age: [Enter age] Date of last menstrual period (LMP): [Enter date]

Developmental History

Developmental delays: [Yes/No and details] School/daycare: [Name and details] Grade level: [Enter grade] IEP/504 plan: [Yes/No] History of counseling: [Yes/No and details] Discipline methods: [Describe] Daily care: - Child needs help with dressing? [Yes/No] - Child needs help with bathing? [Yes/No] - Child needs help with toileting? [Yes/No] Child's sleeping arrangement: [Describe]

Family Medical History

Biological Mother: [Medical history details] Biological Father: [Medical history details]

Social History

Biological Mother: DOB: [Enter DOB] Age: [Enter age] Biological Father: DOB: [Enter DOB] Age: [Enter age] Siblings: [List names and ages] Parental Partner History: [Describe] Household Members: [List] Custody: [Describe custody arrangement] Residence History: [Describe] Caretakers: [List names and relationships] Prior concerns for abuse/exams: [Yes/No and details] Prior agency involvement: [Yes/No and details] Drug/ETOH use in family/household: [Describe] Known child drug/ETOH/vape use: [Yes/No and details] Child history of accidental ingestion: [Yes/No and details] Weapons in household: [Yes/No] Domestic violence exposure: [Yes/No] Pornography/adult sexual activity exposure: [Yes/No] Child has cellphone/Internet access at home: [Yes/No]

Additional Questions/Information

[Document any additional relevant questions or information obtained during the evaluation.]

Patient Exam and History from Patient

[Document 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.]

Patient Terminology for Genitalia and Buttocks

The child's name for the genitals is: [Enter term] The child's name for the buttocks is: [Enter term] The child refers to the labia majora as: [Enter term] The child refers to the inside of the genitals (vestibule, hymen, vagina) as: [Enter term]

Forensic Interview

During the examination and medical history taking, a forensic interview was conducted by [Interviewer name] on [Date]. The interview was: [Describe nature and findings of the interview]

Physical Exam

Medical chaperone: [Name] Examiner: [Name and credentials] Other (if applicable): [Specify] Patient status during exam: [Describe] Vital signs: Height: [Value] (Percentile for age: [Value]) Weight: [Value] (Percentile for age: [Value]) Blood pressure sitting: [Value] mmHg (Percentile for age: [Value]) Head circumference: [Value] General: [Describe general appearance and distress] Head: [Describe findings] Eyes: PERRLA, EOMI, red reflex present, conjunctiva without erythema or hemorrhage, normal fundoscopic exam. Ears: Tympanic membranes clear and mobile bilaterally. Nares: Clear, turbinates within normal limits, septum midline. Mouth/throat: Oropharynx patent, clear, without lesions. Dentition normal for age. Frenulae intact. Neck: Supple without lymphadenopathy or thyromegaly. Full range of motion. Cardiovascular: Regular rate and rhythm, normal S1 and physiologically split S2, no abnormal sounds. Lungs: Clear to auscultation, no wheezes, rales, or rhonchi. Chest/Breast: [Describe breast exam findings, sexual maturity rating, any discharge, erythema, nodules] Abdomen: Soft, non-tender, bowel sounds present, no hepatosplenomegaly. Neuromuscular: Moves all extremities equally, no focal findings, deep tendon reflexes +2 and equal bilaterally, toes downgoing. Extremities: Clear, no clubbing, cyanosis, edema, or deformity. Capillary refill <3 seconds. Normal sensation. Skin: No rashes, lesions, unusual scars, or abnormal bruising. Neurological/Psychiatric: Normal mood, affect, attention span, and concentration for age and development. Behavior appropriate for age and situation. Genitalia: Exam status: [Deferred exam/Patient refused exam/Exam performed] Sexual maturity rating: [Describe] Female genitalia: Hygiene normal, no groin lymphadenopathy. Describe inner thighs, mons pubis, clitoral hood, labia majora/minora, urethral opening, posterior fossa, posterior fourchette. Hymen: [Describe appearance, vascularization, edges, width, scars, clefts, tears] Position during exam: [e.g., supine frog-leg] Saline application: [Yes/No and purpose] Anal: Exam status: [Deferred exam/Patient refused exam/Exam performed] Perianal body and buttocks: [Describe] Gluteal separation and anal exam: [Describe findings] Additional comments: [Document any additional relevant exam findings or techniques used such as lighting, magnification, photographic documentation]

Labs

Following the history and exam: (choose appropriate response, remove sections that are not appropriate) Labs collected today: [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] Other labs/tests: [Specify]

Diagnostic Findings

Reported History: Patient has reported events and symptoms that raise concerns of: [List concerns such as familial substance abuse, physical abuse, domestic violence exposure, methamphetamine, sexual abuse/assault, neglect, manufacturing exposure, other] History from the child in today's evaluation: Reported to the examiner, [Examiner name], that: [Document child's statements] General Physical Exam: Physical exam is normal today with the exception of: [Describe any abnormal findings] Anogenital Exam: Physical and anogenital exam are: [Describe findings]

Summary

Based upon the history available today, as well as today's physical evaluation, there is no indication of: [Specify findings or concerns] Additional Diagnoses: [List if any] Additional Concerns: [List if any]

Follow Up

Follow up on the following tests and evaluations: (only include those mentioned in the encounter, remove the ones not mentioned) - 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 - 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]

Education

(only include those mentioned in the encounter, remove the ones not mentioned) - 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. - Discuss counseling options for the patient and non-offending caretaker. - Discuss discipline strategies. - Review age-appropriate supervision with caretakers. - Provide caretaker education on 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. - Additional caretaker education topics: [Specify]

Referral and Communication

The child is referred back to their primary care provider for further care and special attention to: [Specify] Telephone contact will be made with the primary care provider regarding the findings and recommendations addressed in this report. Telephone contact has been made with the primary care provider regarding the findings and recommendations addressed in this report. Time spent in care, counseling, and coordination for this child: [Specify hours] Additional time: [Specify if applicable] Examiner signature: Name: [Enter name] Credentials: [Enter credentials] Date: [Enter date]

Plan

Pending further evaluation by DHS and law enforcement, this child will remain in the custody of: [Specify] In addition to this examiner, [List others present during debriefing] DHS, Law Enforcement, and the patient's primary care provider have been notified regarding the evaluation and concerns. Medical records from primary care provider/hospital will be requested for review. Caretakers are instructed to notify ABC House medical provider if there is recurrence of genital bleeding or other specified symptoms. Patient will return to ABC House for follow-up in [days/weeks]. Recommendations: - Developmental assessment by: [Specify] - Continued monitoring for developmental progress by: [Specify] - No further contact with: [Specify] pending further evaluation - Separate sleeping arrangements from other household members - Counseling to address issues of: [sexual abuse, domestic violence exposure, familial substance abuse, neglect, family stressors, other] - Improved general supervision - Close supervision of sleeping activities - Close supervision of child's phone and/or Internet activities - Close supervision of play with other children - Other recommendations: [Specify]