Attachment 2f - Patient Discharge Form.pdf

Illinois State Police Division of Forensic Services Step 8 (Patient Label)

Patient Discharge Materials page 1

ISP 6-004 (1/23) Original to patient, copy to hospital medical record

Patient Name DOB/Age Hospital Name Phone # Examining Health Professional Date of Exam

Press firmly and mark all appropriate boxes below while providing patient with information and/or medications.

------------------------------------------------------Case-By-Case Basis According to Risk------------------------------------------------------

HIV-

Must start within 72 hours

Testing Medication

N/A (over 72 hours)

Truvada (Tenofovir 300mg + Emtricitabine 200mg daily) by mouth daily PLUS Isentress (Raltegravir 400mg) by mouth twice a day for 28 days

OR

Truvada (Tenofovir 300mg + Emtricitabine 200mg daily) by mouth daily PLUS Tivicay (Dolutegravir 50mg) by mouth daily for 28 days

Baseline blood testing on case-by-case basis depending on the likelihood of infection among assailant(s)

Syphilis Testing:

preferred

Medication:

not commonly indicated

Due to long incubation periods, presumptive early treatment is ONLY recommended for a KNOWN** exposure to early syphilis within 90 days of exposure (**Known exposure is defined as an assailant with a confirmed early syphilis diagnosis)

Benzathine Penicillin G 2.4 million units IM single dose

Baseline blood testing on case-by-case basis

HPV

Age 9-26 years

Testing: visual screening

Medication

Testing Medication N/A (age)

Gardasil 9 0.5ml IM injection (physician discretion age 26- 45 years)

Gardasil 9 0.5ml IM injection (see age limits)

Hepatitis B

Hepatitis B vaccine booster:______________________

Hepatitis B vaccine:____________________________

Hepatitis B immune globulin (HBIG) 0.06 mL/kg (See guidelines for more detailed instructions)

Baseline blood testing on case-by-case basis

The hospital should provide you with a medication instruction sheet for any medication that was provided to you in addition to this discharge instruction sheet.

*CDC Treatment Guidelines Website: https://www.cdc.gov/std/treatment-guidelines/default.htm **Consider screening pre-pubescent patients for STIs if:

Discussed & Completed

Discussed & Declined

Adult/Adolescent Patients (For alternate therapy refer to CDC guidelines*)

Pre-pubescent patients**

Gonorrhea Testing Genital/Urine Oral Anal

Medication

Testing Genital/Urine Oral Anal

Medication

Rocephin (Ceftriaxone) 500 mg IM injection single dose for patients weighing less than 150kg

OR

Rocephin (Ceftriaxone) 1g IM injection single dose for patients weighing greater than or equal to 150kg

Testing REQUIRED before treatment

Presumptive treatment is not recommended

Chlamydia Testing Genital/Urine Oral Anal

Medication

Testing Genital/Urine Oral Anal

Doxycycline 100 mg by mouth twice a day for 7 days

Testing REQUIRED before treatment

Presumptive treatment is not recommended

Trichomonas Testing Genital/Urine

Medication

Testing Genital/Urine

Medication

Female: Flagyl (Metronidazole) 500mg by mouth twice a day for 7 days

Male: Prophylactic treatment not generally recommended unless indicated by history

Testing REQUIRED before treatment

Presumptive treatment is not recommended

Pregnancy (Emergency

Contraception)

Testing Urine Blood

Medication

Testing Medication

N/A (age or gender)

Plan B Onestep (Levonorgestrel) 1.5mg by mouth single dose up to 72 hours after assault

Ella (Ulipristal acetate) 30 mg by mouth single dose up to 5 days after assault

N/A

Anti-emetic Medication Medication Zofran (Ondasteron hydrochloride) 4 mg by mouth Administer per protocol (if needed)

Tetanus Medication Medication Tdap or Td vaccine Check immunization history

Illinois State Police Division of Forensic Services Step 8 (Patient Label)

Patient Discharge Materials page 2

ISP 6-004 (1/23) Original to patient, copy to hospital medical record

Child is unable to verbalize details of the assault Abuse by a stranger Abuse by assailant known to be infected with or at high risk for an STI Child lives in an area with high rate of STI Child, sibling or another person in household with STI Child or parent requests STI testing Penetration or evidence of recent or healed penetrative injury to genitals, anus or oropharynx Signs or symptoms of STIs (vaginal discharge or pain, genital itching or odor, urinary symptoms, and genital lesions or ulcers)

Counseling/Support Services: As a survivor of sexual assault, you may experience sleep disturbances, anxiety, irritability, depression and other symptoms. These are normal reactions to trauma. You are encouraged to seek help in dealing with the effects of surviving an assault. Rape crisis centers offer free counseling services. You may call your local rape crisis center or 1-800-656- HOPE (4673) to schedule an appointment.

Follow-up Health Care Provider: ____________________________________ Phone Number: ____________________________

< 1 week: If any positive test o Discuss results o Provide treatment (if not administered at initial visit) o Discuss follow-up for infections o Re-check injuries if needed

1-2 Weeks: If tests negative and treatment not provided o Repeat STI testing (detects infections that might not have produced a positive test result at the initial examination)

Pre-pubescent:

o If no infections identified or no diagnostic testing performed, consider follow-up with a qualified medical provider at approximately 2 weeks after the last exposure

1-2 Weeks: If treatment provided at initial visit o Post treatment testing (only if having symptoms) o Burning or pressure during urination o Sores, blisters, white and/or gray growths or warts o Flu- symptoms o Discharge or unexplained bleeding o Pelvic pain or painful intercourse o Rash on groin, mouth, palm of hands, arms, legs or torso o Swollen areas in groin 4-6 weeks o Blood test for syphilis o Blood test for HIV o Assess for anogenital warts o Hepatitis B test (pre-pubescent) o 2nd hepatitis B vaccination (if needed) o 2nd HPV vaccination (if needed) o Pregnancy test (if no period since assault)

3 months o Blood test for syphilis o Blood test for HIV o Assess for anogenital warts o Hepatitis B test (pre-pubescent)

6 months o 3rd Hepatitis B vaccination (if needed) o 3rd HPV vaccination (if needed) o Assess for anogenital warts

Initial for documents and information you have received: _____Kit Tracking information envelope and Pin (Scan QR

_____Medical Forensic services fact sheet code or go the this website: https://paets.isp.illinois.gov/ )

_____Crime Victim Compensation

_____Voucher for follow-up care (if applicable)

_____After Sexual Assault brochure

_____Hospital Billing Notice

Other: (Check if appropriate) o It is recommended that you use condoms or abstain from intercourse until STI prophylactic treatment is completed and all your cultures and blood tests return and are negative.

o Bring these discharge instructions with you to the follow-up appointment. This will help the follow-up healthcare provider.

o If you notice any new bruising, contact the law enforcement agency you reported to so they may take additional photographs.

o If you have any questions regarding the medical forensic examination or medications, please contact the examining health professional listed at the top of the paperwork.

o If you experience severe pain, heavy bleeding, breathing problems and/or other serious medical complaints, you should call

911 or return to the emergency department immediately.

THE ABOVE INFORMATION HAS BEEN REVIEWED AND I HAVE NO ADDITIONAL QUESTIONS AT THIS TIME.

PATIENT SIGNATURE: DATE:

HEALTH CARE PROVIDER SIGNATURE: DATE:

K# and Pin Sticker (Patient copy only)