COORDINATORS TOOL KIT
(print out tool kit for your records)
Exam Forms
Tools to help with the process, chart documentation, and the individual examination log
Adult/Adolescent SANE Kit
The complete Adult/Adolescent SANE Kit form packet - with links to the Vermont Adult Forensic Exam Guidelines, the SANE exam billing forms, and the PHI billing instructions.
Exam Forms:
The Documentation Forms are now in the Evidence Kits.
Put the original in the kit
Scan one copy in the patient’s medical record
Keep a copy in your department for QA
Adult/Adolescent SANE Kit: Exam Forms
Adult/Adolescent: Documentation forms / Kit Instructions
Adult/Adolescent SANE Exam: Guidelines
Billing Forms:
SANE Exam: Sexual Assault Billing Form
Confidential Health Information: (PHI) Billing Form
Out of State Billing Forms (MA-B, MA-2), (NH), (NY)
Antibiotics and HIV PEP: Vouchers for Payment
Discharge Forms:
SANE Discharge Information: Paperwork
Planned Parenthood Follow-Up: Consent and Referral Forms
Pediatric SANE Kit
The complete Pediatric SANE Kit forms packet - with a link to the Vermont Pediatric Forensic Guidelines.
Pediatric SANE Kit: Exam Forms
Pediatric SANE Exam: Guidelines
Intimate Partner Violence (IPV)
IPV Exam: Documentation Form
Drug-Facilitated Sexual Assault
A document for explaining the procedure for screening a patient for possible drug-facilitated sexual assault (DFSA) and the procedure for collecting and transporting urine samples for testing in suspected DFSA cases. Included are suggestions for patient education regarding the risks and benefits of testing, the procedure to request testing, and the procedure for obtaining the test results.
DFSA: Exam Forms and Instructions
Strangulation
The complete Strangulation exam form packet - with additional resources.
Strangulation: Exam Forms
Strangulation Resources: Recommendations + Signs and Symptoms + Assessment Card + Pregnancy + Neck Structures
Documentation Audit Forms:
A hospital coordinator is expected to audit all the cases at their hospital. This will help improve the quality of forensic nursing care and catch problems early.
EXAM LOG
Log all cases in the UPS Trackpad - even if you do not complete an exam kit. Cases with no kit number should be logged in as “NA/your initials/the date/the time,” for example: NA/RL/10-1-2019/3:45p. Once you have entered all the information, click START. You will not receive a confirmation message that your case as been entered.