TeleSANE Program Forms
The UAMS Institute for Digital Health & Innovation TeleSANE program provides documentation to assist in the creation of a statewide standard care of practice. All of the following documents make-up the patient documentation packet.
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Patient Discharge Form
Form provided to the patient with pertinent information.
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Sexual Assault Forensic Examination Record
Forensic examination documentation record.
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Downtime Order Set Form
Checklist form used to determine patient care needs.
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Spoke Site Nurse Checklist
Checklist for clinicians to ensure they have performed each step of the patient care.
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Discharge Medication Template
Medication prescription template for nPEP medications.
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Chain of Custody Log Form
Documentation form for chain of custody.
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Sexual Assault Medical Forensic Examination Consent Form
Informed Consent Form
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TeleSANE Chart Tips
Checklist to aid in completing a SANE chart.
Reimbursement Forms
Through the state of Arkansas both patients and facilities are entitled to reimbursement compensation.
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Application for Crime Victim Compensation (patient)
Patient Reimbursement Compensation Form should be provided to each patient.
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Arkansas Crime Victims Reparations (facility)
The facility should submit a reimbursement compensation form for every patient treated.
Workflow Charts
The TeleSANE Program has created easy to follow workflow charts for many of the step-by-step guidelines when treating sexual assault patients.
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Adolescent Workflow
To be utilized if patient is 17 and under.
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Consent to Treatment Workflow
To be utilized to determine if patient has provided consent to treatment.
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TeleSANE Consult Workflow
Created to aid clinicians in understanding the flow of a consultation call.
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HepB Unknown Status Workflow
Utilized to determine treatment for patients who may have been exposed to HepB.
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HepB Known Status Workflow
Utilized to determine treatment for patients who may have been exposed to HepB.
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HIV Post-Exposure Prophylaxis Workflow
Utilized to determine treatment for HIV prophylaxis.
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nPEP Needs Assessment Workflow
Utilized to determine treatment for HIV prophylaxis.
Telecart & Technology Guides
Helpful charts, step-by-step guides, and images to help with utilizing the telecart and technology associated with the TeleSANE Program.
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Accessing a TeleSANE Consult
A step-by step guide with images for powering on the cart and tablet to begin a consult.
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Connecting the Lutech SD 300 Camera
A step-by-step guide with images on connecting the camera to the telecart.
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Spoke Site Start-Up Consultation Call Workflow
A step-by-step guide with images on how to start a consultation call request.
Post Consultation Survey Links
Post consultation surveys allow TeleSANE to review process, policy, and procedure for all stakeholders, including the patient. Encourage the patient to complete a survey post consultation services. TeleSANE would love to hear from each Spoke Site Nurse and Advocate post consultation services.