CONFIDENTIAL MEDICAL RECORD
Medical Aftercare
SARC……………………….
Name…………………………………………………….D.o.b………………..Age......
Address......
Telephone Number......
Completed by:……………...... Signed:………………….. ……Date………………
CONSENT TO CONTACT – Consent can be made:
a)Home - in writing/by telephone
b)GP in writing/by telephone
c)with ...... (other specify)
GENERAL PRACTITIONER
Name......
Address......
Tel No:
......
MEDICAL HISTORY
General Health......
......
......
......
Previous Illnesses......
......
Operations......
......
......
Medication......
......
Allergies......
......
GYNAECOLOGICAL HISTORY
Periods......
LMP......
Use of tampons......
Pregnancies......
Pregnancy test at St. Mary’s (circle) Yes/No Result......
HIV PEP
Detail of exposure:
Date / time of assault…………………………… Time interval to examination……………………...
Time interval to first dose PEP…………………
Risk of exposure;
Type of exposure: Anal receptive / vaginal receptive / oral receptive/splash semen to eye
Other…………………………..
Ejaculation occurred? Yes / No / Unknown
Condom used throughout? Yes / No / Unknown
Aggravating factors e.g.Injuries in contact with assailant’s bloodor semen Yes / No
Assailant details:
HIV status: positive / negative / unknown
Sexuality: MSM / heterosexual / unknown
IVDUYes / No / Unknown
UKYes / No / Unknown but probably
Foreign born / lived Yes / No / Unknown but probably
Country………………………………. High risk / Low risk
According to SARC flowcharts HIV PEP is:
Not appropriate / to be considered / recommended
Where PEP to be considered or recommended
Is complainant;
16 years old / pregnant / breast feeding/ suffering serious medical condition Yes / No
(If yes to any of these discuss with GU on call and document outcome)……………………………
……………………………………………………………………………………………………………….
………………………………………………………………………………………………………………..
Discussed with complainant:
Rationale / Potential side effects / regime / importance of compliance & follow up. Yes / No
Starter pack given; Yes / Declined…………………………………………………. Batch no………………Exp Date………..
GUM form faxed to GU clinic Yes / No
Name of clinic…………………………………………..
Clinic contact number given to clientYes
Yellow Pharmacy prescription completed and placed in Logbook pouch Yes
Patient info sheet given: Yes / No
Hep B PEP
According to SARC flowchart Hep B Pep is: Not appropriate/Recommended
According to SARC flowchartHep B Immunoglobulin is: Not appropriate/Recommended
Hep B givenYes / Declined
Site………………………..Batch no………………….Exp date……………….Dose……………..
GP / GUM letter Given to complainant / Faxed / To be posted
(details………………………………………………………………)
Clinic contact number given to client if attending GU clinic Yes
Yellow Pharmacy prescription completed and placed in notesYes / No
Patient info sheet given Yes / No
Emergency Contraception
LMP…………………. Hours post unprotected sexual intercourse (UPSI)………………
Not appropriate Declined Levonelle given
Declined……………………………………………………
Other......
Levonelle given Batch number………………………..Expiry date……………..
Yellow Pharmacy prescription completed and placed in notesYes / No
Follow up advice Yes / No
IUCD Considered / discussed / recommended…………………………………………..
Safer Sex
Safer sex
(barrier methods advised for 3 months post assault) discussed.Yes / Not indicated
Self Harm Risk
Any specific concerns arisen regarding imminent risk of self harm?Yes / No
Further information / action:
......
GP Letter
Given to complainant:Yes / NoPosted to GP: Yes / No
PLEASE REMEMBER TO KEEP COPY IN THE NOTES OF ANY LETTERS TO OTHER AGENCIES such as GP, GU clinic, A&E etc.
Child protection / vulnerable adults
Are there child protection / vulnerable adult concerns regarding this case?
Yes No
Urgent social services referral required?
YesNo
Referred to: (Social services or other appropriate agency):Is areferral required within:
Name:______(Trust Safeguarding team)
1 working day
Office:______Or
Tel no.:______5 working days
Referred by:______Referred by:______
Date and time of referral:______Date:______
Followed up in writing by:______
Date of letter:______
Brief outline of main concerns:
______
Additional Notes (use additional information page as required and tag to this form)
......
Page 1 of 3 17th June 2009 CW CM 9288