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