Female examination template 1

INTERVIEW/EXAM ABUSE/NEGLECT/EXPOSURE ALLEGATION

DATE OF EVALUATION: [Enter the date of evaluation in MM/DD/YYYY format] PATIENT ACCOUNT NUMBER: xx-xx-xx PATIENT NAME: [Enter the patient's full name] DOB: patient's date of birth in MM/DD/YYYY AGE: patient's age EXAMINING MEDICAL PROVIDER: [Dr. Karen Gray DNP,CPNP-AC/Dr. Carol Chervenak, MD/Barba Beatty, CPNP] ATTENDANT: Alyssa Critchfield, CMA/none/not applicable ACCOMPANYING THE PATIENT: [Enter the guardian's name and their relationship to the patient] In addition to this Examining Medical Provider; [Dr. Karen Gray DNP,CPNP-AC/Dr. Carol Chervenak, MD/Barba Beatty, CPNP], the following were present for the review today: ODHS: [Enter the name of the DHS worker], [Select the appropriate county: Linn County/Benton County] FORENSIC INTERVIEWER: [Select the forensic interviewer's name: Heather Perez/Katelynn Weisner/Amanda Patterson/N/A] LEA: [Enter the rank and name of the law enforcement agent] [Select the appropriate department: 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] OTHER: [Specify any other individuals present, if applicable] This is a/an [patient’s age] female who is brought to ABC House today for evaluation of possible: [abnormal anogenital finding previously observed by examiner/sexual abuse/physical abuse/neglect/medical neglect/exposure to domestic violence/exposure to methamphetamine manufacturing/parental/caretaker substance use/abuse and drug endangered environment/problematic sexual behavior]

HISTORY OF ALLEGATION:

The ABC House personnel were contacted about the above concern by [Enter 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: [Provide a numerical list summarizing each uploaded file. Use alphabetical format for multiple written report files for each organization. Each entry should be concise and clearly organized. Do not use recorded verbal reports.] 1) DHS Screening Report: Screening Report: [enter screening report ID # from uploaded file] Dated: [insert date reported from 307 form] [Summarization of 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: [enter case report # from uploaded police report file] Dated: [insert date reported from law enforcement case report] [Summarization of 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's name] DOB: [Enter date of birth in MM/DD/YYYYY format] -[enter patient account # from uploaded previous ABC House encounters] Dated: [insert encounter date] [type of encounter]. [Summarization of encounter from uploaded previous ABC House medical records. Do not include any recorded verbal history from today's evaluation] 4) Samaritan Health Services Medical records for [enter patient's full name] [Enter the patient's date of birth in MM/DD/YYYY format] 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 OF ALLEGATION FROM PARENT/GUARDIAN:

Indications for the comprehensive medical examination and necessary testing were explained, and consent was obtained with: [Specify who gave consent] History Provided By: [name of historian and relationship], the patient, and review of medical records. Current concerns and medical history are privately reviewed with the above professionals with the consent of the [name of historian and relationship]. Questions to address: - What are you most concerned about regarding [patient's first name] today? [document response verbatim]. - What does [patient's first name] know about today's exam? [document response verbatim]. - Briefly tell me what the circumstances are that brought you and [patient's first name] to the ABC House today: [document response verbatim]. - Have you talked about what's going on with them? [Yes/no and document verbatim what the historian and patient have said].

PATIENT PAST MEDICAL HISTORY:

BIRTH HISTORY: - Prenatal care: [Unknown/Yes/No and details] - Maternal pap smear: [Unknown/Yes/No and details] - Prenatal drug/alcohol exposure: [Unknown/Yes/No and Specify substances and details] - Delivery details: [normal spontaneous vaginal delivery/C-section/unknown/other: and details] - Gestational age: [Enter weeks/unknown] - Birth weight: [Enter birth weight/unknown] - Pregnancy/delivery complications: [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 and duration] - Discharge details: [Describe/Unknown] IMMUNIZATIONS: - [If the patient is up to date on vaccines, input 'Vaccinations are up to date as recorded in Oregon VISS.'] - [If the status is unknown, input 'unknown.'] - [Include sections for missing vaccines from the uploaded immunization file and the historian's verbal response.] ALLERGIES: [Input information for allergies from the uploaded file titled 'allergies' and include any additional allergies not listed in the file that are provided by the historian in a list format.] CURRENT MEDICATIONS: [Input information for current medications from the uploaded file titled 'medications' and include any additional medications not listed in the file that are provided by the historian in a list format including name of medication and dose.] OB/GYN HISTORY: (provide details on premenarchal status, age at menarche, and date of last menstrual period. Only include those mentioned in the encounter, remove the ones not mentioned) - Patient is [premenarchal/menarchal and age of onset of menarche if applicable]. - Last Menstrual Period: [enter date of last menstrual period]. - Details of menses: Menses is [regular/irregular]. Frequency and duration: [Enter frequency of menses and duration]. [Has have 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 and if yes, when: , and if she had pain with exam]. RECENT/ACUTE ILLNESS/INJURY: [In list format input information for illnesses or injuries that have occurred in the two weeks prior to the examination today from the uploaded file titled 'patient medical history' and include any additional hospital admissions and surgeries not listed in the file that are provided by the historian in a list format, including the dates if applicable. If the information is unknown, input 'unknown.'] GENERAL HEALTH: The child’s general health is good with typical childhood illnesses/Child has a complex medical history. [input in list format emergency department visits where chief complaint was an injury or UTI with dates and diagnoses since birth, where chief complaint was an injury or UTI with dates and diagnoses since birth, and well child visits with dates from the last three years uploaded from the file titled ‘chart review’]. PROBLEMS LIST: [Input medical problems with dates from the uploaded file titled 'problems list' in a list format.] MENTAL HEALTH SPECIALIST: [Unknown/Yes/No and details] PRIMARY CARE PROVIDER: [Unknown/No/Yes and name] - Date of Last Well-Child Visit: [Date/unknown] DENTIST: [Unknown/No/Yes and name] - Date of Last Dental Visit: [Date/unknown] DEVELOPMENTAL HISTORY: Patient is delayed/not delayed. xxxx SCHOOL PERFORMANCE/DAYCARE: (only include those mentioned in the encounter, remove the ones not mentioned) - ATTENDS DAYCARE: [Specify daycare attendance: Yes/No/Unknown, and provide name and details if Yes.] - ATTENDS SCHOOL: [Document school attendance only if the patient attends school: Yes/No. If Yes, include Name and details.] - ACADEMIC PERFORMANCE: [Assess academic performance: Above average/Average/Below average/Unknown.] - ATTENDANCE: [Evaluate attendance: Good/Fair/Poor/Unknown.] - SUSPENSIONS & EXPULSIONS: [Note any suspensions/expulsions: Yes/No/Unknown and provide details if Yes.] - IEP/ 504 PLAN: [Indicate if there is an IEP/504 plan: Yes/No/Unknown.] - DIFFICULTIES GETTING ALONG WITH OTHER CHILDREN: [Indicate if there are difficulties getting along with other children: Yes/No/Unknown and provide details if Yes.]

REVIEW OF SYSTEMS:

[For each system below, replace positive symptom with history described by historian or patient. Replace with 'unknown' if unknown.] - 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.] - GENTIOURINARY: 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.] XXXX

FAMILY MEDICAL HISTORY:

There is a family history of: [unknown/non contributory/alcoholism/asthma/ADHD/ADD/bleeding disorder/bone fragility/deafness/diabetes/substance abuse/psychiatric illness/seizures and enter details of any positive answers in list format with relationship to the patient].

SOCIAL HISTORY:

- BIOLOGICAL MOTHER: [Enter name], DOB: [Enter mother's date of birth in MM/DD/YYYY format], Age: [calculate and enter age] - BIOLOGICAL FATHER: [Enter name], DOB: [Enter father's date of birth in MM/DD/YYYY format], Age: [calculate and enter age] - 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 ALCHOL 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] [Input date, allegation, name and status from uploaded files titled 'reports' in detailed list format if applicable]. - ADDITIONAL QUESTIONS/INFORMATION:[Document any additional relevant questions or information verbally reported by historian]

FORENISIC INTERVIEW:

(choose appropriate response, remove sections that are not appropriate. Do not use recorded verbal history. Use uploaded forensic interview file) -No forensic interview was conducted. -Prior to the examination and medical history taking, a forensic interview was conducted by Heather Perez/Katlynn Weisner/Amanda Patterson on [enter date of forensic interview]. 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 Heather Perez/Katlynn Weisner/Amanda Patterson on [enter date of forensic interview]. The interview was observed/reviewed by the examiner from the monitor room/following its completion. -The following information is a summary of statements [enter patient's 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 of forensic interview]. [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 PHYSICAL EXAM:

EXAMINATION STATUS: 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 [Dr. Karen Gray DNP,CPNP-AC/Dr. Carol Chervenak, MD/Barba Beatty, CPNP], Alyssa Critchfield, CMA, [enter other medical professional names and title if applicable], and the patient [enter patient’s name]. During the examination [enter patient’ first name] is: xxx VITAL SIGNS:(choose vital signs discussed in this encounter and remove those that are not discussed.) Height: [Value] (Percentile for age: [Value]) Weight: [Value] (Percentile for age: [Value]) BMI: [Value] for age. Blood pressure sitting: [Value] mmHg Head circumference: [Value] (Percentile for age: [Value]) GENERAL: Patient is a/an [patient's age] [enter 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: XXXX - 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 and describe abnormal findings.] - NEUROLOGICAL/PSYCHIATRIC: [Normal mood, affect, attention span and concentration for age and development. Acting appropriate for age and situation and describe abnormal findings.] - GENITALIA: (choose appropriate response, remove sections that are not appropriate) [Deferred exam/patient refused exam/parent refused exam if applicable]. - ANAL: (choose appropriate response, remove sections that are not appropriate) [Exam is deferred/Patient refused exam/Parent refused exam] 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.

HISTORY FROM THE CHILD:

With the child and xxx/Alone with the child, I again explained that as a pediatric nurse practitioner, my job is is to ensure that she is safe and healthy. I asked [enter patient's name] if she knew why she had come in for an exam today. She said: [enter patient's response in quotes]. I explained that I often see children who have been hurt or touched in a way that they did not like. I asked [enter patient's name] if this has ever happened to her. She said: [enter patient's response in quotes]. I asked [enter patient's 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’s name] was escorted back to the waiting area to the care of [person accompanying the patient].

LABS:

(choose appropriate response, remove sections that are not appropriate.) Following the history and exam: - 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 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 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 and hair color] - Other labs: [Specify] - Imaging: [Specify]

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’s 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’s name] (dot phrase) ANOGENITAL EXAM: [Patient’s name] (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, there is EXAMINING MEDICAL PROVIDER WILL ANNOTATE. [Enter detailed list of any disclosures, verbal statements verbatim, 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 with quotations for verbal responses].

EDUCATION:

Caretaker education was done around: (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. - 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 reoccurrance of genital bleeding. - Caretakers are instructed to notify ABC House medical provider if there is reoccurrance of [describe], - Additional caretaker education topics: [Specify]

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:]. [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] and are deferred to ODHS. I met with [parent/guardian] to discuss the evaluation and recommendations. In addition to this examiner, xxxx 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: (only include those mentioned in the encounter, remove the ones not mentioned) - 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] RECOMMENDATIONS: Xxxxx ICD-10 Codes: [list format with descriptor] 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) Signed by: