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    Sexual Assault Standing Orders and Treatment Plan

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    Accessible Journal Media: Peace Corps Documents
    This document provides a treatment plan and standing orders for a Peace Corps volunteer who has experienced a sexual assault. It includes details on initial screening, recommended medications, follow up services, and sign off from medical providers.

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    © All Rights Reserved

    Sexual Assault Standing Orders and Treatment Plan

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    Accessible Journal Media: Peace Corps Documents
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    This document provides a treatment plan and standing orders for a Peace Corps volunteer who has experienced a sexual assault. It includes details on initial screening, recommended medications, follow up services, and sign off from medical providers.

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    PEACE CORPS Attachment H SEXUAL ASSAULT STANDING ORDERS AND TREATMENT PLAN

    Original Title

    SEXUAL ASSAULT STANDING ORDERS AND TREATMENT PLAN

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    This document provides a treatment plan and standing orders for a Peace Corps volunteer who has experienced a sexual assault. It includes details on initial screening, recommended medications, follow up services, and sign off from medical providers.

    Copyright:

    © All Rights Reserved
    183 views2 pages

    Sexual Assault Standing Orders and Treatment Plan

    Uploaded by

    Accessible Journal Media: Peace Corps Documents
    This document provides a treatment plan and standing orders for a Peace Corps volunteer who has experienced a sexual assault. It includes details on initial screening, recommended medications, follow up services, and sign off from medical providers.

    Copyright:

    © All Rights Reserved
    of 2

    PEACE CORPS Attachment H

    SEXUAL ASSAULT STANDING ORDERS AND TREATMENT PLAN

    Name (Last First (MI) DOB: VOL ID: Today’s Date:

    _________________________________________________________________________________________________________

    CURRENT MEDICATIONS:

    ALLERGIES (include reactions):

    Initial General Medical Screening & Laboratory Pre-Screening Lab Tests for HIV PEP
    (Check box & Initial Tests Ordered) (Check box & Initial Tests Ordered)
    Physical exam CBC (complete blood count)
    Mental Health exam Comprehensive Metabolic Panel
    Counseling Referral- specify in country or OMS/COU (GLU, Ca, T. PRO, ALB, Na, K, Cl, CO2, BUN, Creat, ALP,
    ALT, AST and Bili)
    RPR or VDRL Reflex HIV Antibody Screen
    Gonorrhea HIV Medication Counseling
    Chlamydia Pre-Screening Lab Test & Counseling for Pregnancy
    HIV Antibody Screen
    Hepatitis B Testing- HbsAg and HbBs Ab * Pregnancy Test (according to history)
    Hepatitis C Testing Other:
    Status of Tetanus immunization
    Medication Standing Orders Administering Clinician
    Signature/Date and Time
    Azithromycin 1 gm po (antibiotic for Chlamydia and Gonorrhea)

    Ceftriaxone 250mg IM X1 dose (antibiotic for Gonorrhea)

    Truvada (emtricitabine/tenofovir)200mg/300mg daily for 28 days +


    Isentress (raltegravir)400 mg 2 times/day for 28 days (HIV prevention)
    Metronidazole 2 gm oral X 1 dose (antimicrobial for trichomonas)
    (Withhold if pregnant or history of recent use of alcohol). Consult OHS.
    Plan B One Step (Levonorgestrel 0.75mg tab) 2 tabs at once

    Trimethobenzamide (Tigan) 200mg 3 times/day as needed (for nausea)

    ***For medications for sleep or anxiety symptoms, consult COU.

    Substitutions for above or other medications given:


    Doxycycline 100mg oral 2Xday for 7 days (Chlamydia)
    (if allergic to PCN/Ceftriaxone) Azithromycin 2gm po instead of 1 gm.
    Other:

    Provider Initial and Printed Name_____________ _____________________________________


    Provider Initial and Printed Name_____________ _____________________________________

    June 2015
    Name (Last- First -(MI) DOB: Today’s Date:
    VOL ID

    Recommended Follow-up Services (if checked): Notes: (dates of future appts., etc.)

    At 72 hours post assault:


    PEP evaluation and tolerance (if PEP given)
    Review of laboratory results (serum and cultures)
    If HBsAb negative, give HBIG and Hepatitis B vaccine #1
    Assess mental and physical health
    Perform a PC-PTSD (TG545
    At 2 weeks:
    Repeat Pregnancy Test
    Repeat Gonorrhea / Chlamydia test (if symptomatic or
    decline initial treatment)
    CBC (if PEP given)
    LFTs (if PEP given)
    Renal function (if PEP given)
    Assess mental and physical health
    At 4 weeks:
    Assess mental and physical health
    Perform a PC-PTSD (TG545)
    If HBsAb negative, give Hepatitis B vaccine #2
    At 6 weeks:
    HIV Test
    At 8 weeks:
    Repeat CBC and/or LFT if abnormal at 2weeks
    Assess mental and physical health
    Perform a PC-PTSD (TG545)
    At 3 Months:
    Serum test for Syphilis (VDRL or RPR)
    HIV Test
    Assess mental and physical health
    Perform a PC-PTSD (TG545)
    At 6 Months:
    HIV test
    Hepatitis C Test
    Assess mental and physical health
    If HBsAb negative, give Hepatitis B vaccine #3
    *HbsAg prior to PEP, HbsAb immediately post assault to check Hep B immunity

    Provider Initial and Printed Name _____________ _____________________________________


    Provider Initial and Printed Name _____________ _____________________________________

    June 2015

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