All exams MUST be submitted on state exam forms, NO EXCEPTIONS.

Transcription

1 IMPORTANT All exams MUST be submitted on state exam forms, NO EXCEPTIONS. Exams submitted on facility forms will not be reviewed by the Commission and will be returned to you to be rewritten onto state exam forms. This is the only way for the Commission to evaluate all applicants fairly. Common mistakes and how to avoid them: Mistake # 1: Sending in exams on facility-specific forms. Instead: Send them in on the latest state exam form (January 2016 version). Mistake # 2: Sending in an exam with missing pages. Instead: Double check that you are sending in the state exam form, pages In particular, make sure to include page 15, HIV Risk Assessment/Medications/Referrals. Mistake #3: Blanks and missing information. Instead: Include medication names and dosages. Explain unknown or attempted answers. Note when patient declines an option. Mistake #4: Sending in extra pages. Instead: Send in the state exam form, pages Other medical records or extra exams will be shredded. Mistake #5: Not de-identifying your charts. Instead: Make sure ALL identifying information is blacked out or removed. Refer to the instructions if you re unsure what information this includes. If the Commission feels they cannot fully evaluate your competency for the reasons above or any other reason, you will be asked to send in additional information during the next application cycle. Revised August

2 Oregon SANE/SAE Certification Application First Name MI Last Name Address City, State, Zip Code Phone # Address License Number County of Employment Employer Medical Director Work Address Work City, State, Zip Code Work Phone # Please submit along with this completed application packet: Copy of certificate from 40-hour SANE/SAE Training (check appropriate box below) Oregon didactic course IAFN didactic course Other didactic course Application fee: $100, non-refundable. Please send check or money order, payable to the Oregon SANE Certification Commission. Please do NOT use staples in your application. Thank you! Active Practice Verification: By signing below, I affirm that I hold a current unrestricted License in Oregon and that I am actively practicing in a clinical practice with an average of 16+ hours of direct patient contact per month. Applicant Signature Date Mail all materials to: Oregon SANE/SAE Certification Commission 3625 River Road North, Suite 275 Keizer, OR Revised August

3 Non-Clinical Requirements Validation Form Applicant Name Activity Law Enforcement Agency Ride Along and/or Case Review Date Signature Title and Agency Contact Phone Number Criminal Court Observation Type of Case: Judge: District Attorney s Office Observation County: DA: Advocacy County Victim Assistance Program and/or Non-Profit Victim Assistance Program Crime Lab Tour and Orientation Location: Recommended/Optional SART Meeting Other: Revised August

4 Speculum Exam Validation and Evaluation Checklist (Applicant must submit either this form or Speculum Exam Exemption Waiver Request Form) Applicant Name Please evaluate each skill: 1 = Demonstrates competence 2 = Needs more practice Introduces self and role Explains procedure Confirms consent for exam Offers patient chance to empty bladder (collects urine when appropriate) Wears gloves Skill Selects appropriately sized speculum, lubricate with water-based lubricant or water Maintains patient dignity, drape appropriately Identifies and inspects labia majora, labia minora, general appearance, injury assessment Avoids startling patients: explains actions, instructs patient to relax, touches appropriately Retracts labia majora, identifies and inspects clitoris, urethral meatus, anterior vaginal wall, hymen, fossa navicularis, posterior fourchette, perineum Inserts speculum Rotates and opens speculum, assures proper placement Visualizes cervix (fornix, anterior cervix, cervical os), describes findings Identifies techniques for collecting swabs Removes speculum Removes gloves, washes hands Documents observations Observes clean technique throughout procedure Revised August

5 Evaluators: Please personally observe and evaluate each speculum exam individually. Evaluator Name, Title, Medical Facility Date Comments Revised August

6 Speculum Exam Exemption Waiver Request Form (Applicant must submit either this form or Speculum Exam Validation and Evaluation Form) If you are a health care professional who conducts speculum exams as part of your routine medical practice, please fill out this form to request a waiver exempting you from the ten observed speculum exams required for certification. Full Name Title Address Phone # Medical Facility Approximately how many speculum exams do you conduct in a year? (Answer must be >10.) By signing below, I am verifying that I conduct more than ten speculum exams in a year, as part of my routine medical practice. Signature of Applicant Date By signing below, I am verifying that the above applicant conducts more than ten speculum exams in a year as part of their routine medical practice, and that I have personally observed and can attest to their competency. Signature of Supervisor Date Revised August

7 Sexual Assault Medical Forensic Exam Competency Checklist Observing exam: The recommendation of the Oregon SANE Certification Commission is that the applicant should first observe a live or mock exam by an experienced SANE. A reflection is required for this Observing exam, but no competency checklist or chart should be submitted. Performed exams: The second, third, and fourth exams should be a combination of Being Observed by an experienced SANE and Independent. Guidelines: At least one exam must be completed as Being Observed and at least one exam must be completed as Independent. Two of these exams may be completed as mock exams. The Commission strongly recommends that only one of them be a mock exam to reduce the chance of being asked for additional information. Along with this form, please submit your de-identified charts on the state Oregon Sexual Assault Medical Forensic Exam Form and exam critiques and self-reflections for all three performed exams. Exam One: Date: Being Observed Independent Mock Please check all that apply for your three performed exams. Exam Two: Date: Being Observed Independent Mock Exam Three: Date: Being Observed Independent Mock Applicant Name Please evaluate each skill: 1 = Demonstrates competence 2 = Needs more practice Patient medically cleared before exam. Skill Set up room, gather supplies: SAFE Kit, forms, speculum, blankets, swab dryer, water, alternative light source. Introduce self to patient, explain that an advocate has been called. Available options explained: Medical assessment with evidence collection, <84 hrs post-assault: Includes sexual assault evidence kit, urine pregnancy test, STI prophylaxis, emergency contraception, referrals, follow-up care. Medical assessment without evidence collection, any time post-assault: May include urine pregnancy test, STI prophylaxis, emergency contraception, referrals, follow-up care. Options for reporting and non-reporting evidence collection explained. Exam One Exam Two Exam Three Revised August

8 Respect demonstrated for patient choices and autonomy. Explains and obtains Exam Consent, Medical Release, and SAVE Form. Must receive a 1 in this category for exam to count toward certification. Mandatory report made if applicable. Medical screening discussed. Presence of advocate and/or support person offered. Health history obtained as necessary while protecting patient privacy. History of assault obtained. Collection, packing, and processing of urine verbalized if applicable. Option/process to obtain clothing for evidence explained. Has patient undress on sheet of white exam paper or sheet. Places each item of clothing in separate bag to be labeled. Swab dryer disinfected with bleach prior to use and used appropriately. Head to toe physical exam and evidence collection completed per history. Detailed anogenital exam and evidence collection completed per history. Option for photography explained to patient if available. Process explained. SAFE kit processed properly during exam: drying, packaging, labeling, etc. STI prophylaxis and emergency contraception offered where indicated. Shower and change of clothes offered if available. Discharge instructions provided, including: meds given, follow-up care, referrals, injury/wound care. Safety plan developed with advocate. Process for securing each bag with patient label or kit number (if anonymous), date/time collected, and SANE signature verbalized. Chain of evidence process described. Debrief completed with patient. Documentation completed: SA form, consents, bodygrams, photos. Fill out Log Book (kept in locked area) with date, MRN, patient name, exam start and finish times, and SANE name. Swab dryer disinfected with bleach solution, exam area thoroughly cleaned. Applicant Signature: Preceptor Name(s) ( Being Observed exams): Preceptor Signature(s) ( Being Observed exams): Revised August

9 Sexual Assault Medical Forensic Exam Critique and Self-Reflection Instructions Please attach a critique and self-reflection for each exam, observing and performed. Guidelines are below for each type of exam. Be clear and thorough, with specific examples. Include a reflection on any bias, emotional reactions, and thoughts about the SANE process. Observing: Quality and elements of the exam Flow of the exam Three parts that went well Three parts that could be improved Being Observed: Quality and elements of the exam Feedback from your preceptor regarding: Flow of exam Three parts that went well Three parts that could be improved Independent: Quality and elements of the exam Identify and list what made you uncomfortable and why Describe your organization, flow of the examination, and rationale What went well and why Opportunities for improvement Revised August