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WellSpan Health
York Hospital
Gettysburg Hospital
Forensic Medical Record
Adult/Adolescent
Form ED-129 R-5/2012
WellSpan Health
York Hospital
Gettysburg Hospital
Forensic Medical Record
Adult/Adolescent
Form ED-129 R-5/2012
Medical Advocate Present to address safety plan  Yes  No
See ED Record for Data
SAFETY PLAN CHECKLIST FOR DISCHARGE (if not done by advocate)
Medication Flowsheet
Allergies
Date/Time
Medication
Initials
NO
____
____
1. Has a safe place to go upon discharge, and is able to identify alternatives if this
place becomes unsafe.
____
____
2. Discussed personal safety at home/public areas.
Dose
Route
CEFIXIME (SUPRAX) AND
400 MG
PO
AZITHROMYCIN (ZITHROMAX)
AND
1 GRAM
PO
____
____
3. Identifies a support person.
EMERGENCY CONTRACEPTION
AND
□ 1 TABLET
PO
____
____
4. Information given about counseling options and the benefits of getting counseling.
□ 2 TABLETS
□ 4 MG
ZOFRAN
Site
YES
PO
□ 8 MG
ANY OTHER SAFETY ISSUES ADDRESSED:
TAKE HOME PACK
□ FLAGYL
2 grams
PO
□ EMERGENCY CONTRACEPTION
1 tablet
PO
_____MG
PO
□ ZOFRAN
*If answered yes for domestic violence screen, list interventions here
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Nurse Initials/Signature
Initials
__________________________________________________________________________________________
Signature
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Discharge Vital Signs: Temp____ Heart Rate_____ Respiratory Rate____ Blood Pressure (age 5 and up)__________
Initials________/Date_______
150 Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
Page 24 of 28
Initials________/Date_______
Page 25 of 28
Appendices
151