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MAR 27 2015' b*t\b'~o<,/osr/o7

Abel Acosta, Clerk
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H. EXAM / CONSULTATIONS / FINDINGS & FOLLOW-UP:

PERSONNEL INVOLVED (PRINT) PHONE

Q 'Ctf&fhvyrtl fa-zd. History taken by:

<J~, <?<?, W 6*^—&r<--*rr-M

Physical examination performed by:

Specimens labels and sealed by:

Assistant:

Psychosocial assessment taken by:

N/A • Report attached /

Interview observed:

D Yes jarfvio

CONSULT:

TIME CALLED

UL *fii&T—rM^yURESPONDED

IMPRESSIONS, FINDINGS, AND FOLLOW-UP:

Pediatric Examinations Reveals:

• Physical Findings

• Exam consistent with history

• Exam inconsistent with history

Q Specific for abuse

Q Non-specific for abuse

Mg?

*i>**a>*fSf m<A?

SERVICE

No Physical Findings

J3--'Exam consistent with history

Q Exam inconsistent with history

DOCTOR

IMPRESSION:

: Sz^M${ rtd-?<,£*C -~ sdAd fo&•&<&& <^r\ f^»<^7

PATIENT RELEASED TO: z&T

PHYSICAL EXAMINER (print /signature):' -"J /£> <*£L/2 -, /ll.^~)f W' 7/ J "• tOCT'**^-v ^v^/^y / v/

O-^flome DISPOSITION: • Admit to

CONDITION AT DISCHARGE: J3"G

PLANJ-rCTieck if applicable)

Good Q Satisfactory

eassurance regarding health of genitalia.

'Retym to regular family doctor for routine medical care.

56py of medical report to caseworker and/or lawenforcement agency.

Other.

AFTERCARE INSTRUCTIONS: ^______

• Follow up appointment ~~

.ja^Counseling: Counseling:. £-"/<C '/""^

Followup lab:

Q Transfer to ED

• Serious

Atorttfen and verbal information went to parent / guardian / patient (circle) r «"• ACI Q Return to school/work Q PCP .^TLiterature Q Referral list

Q^fKnliapaXary guidance

15400 (11/02)

CookChildren's.

801 Seventh Avenue

Fort Worth, Texas 76104-2796

PHYSICAL & SEXUAL ABUSE

MEDICAL PROTOCOL

(Page 9 of 9)

• Physician list

^-iXiimts—•—

PRINTOR IMPflINT PATIENT INFOHMATION
RUN DATE: 10/11/07

RUN TIME: 08 2 0

Cook Children's HCIS LAB **LIVE**

Summary Discharge Report

LOCATION

PAGE 1

j? &£{'• Ctfl &/£~o&£c> '* &9*&U/&A Ck**]-7iX*S

PATIENT: DEHOYAS,ROSA

REG DR: COFFMAN,JAMYE L MD

Test Day Date

HCG SERUM

CHLAMYDIA GENPR

GONORRHEA GENPR

HEP C VIRUS

1 JUN 5

1 JUN 5

1 JUN 5

1 JUN 5

Patient: DEHOYAS,ROSA

ACCT #: |V00006053842| LOC:

AGE/SX: 14/F ROOM:

STATUS: REG CLI BED:

Time Result

1625 NEGATIVE

1600 NEGATIVE

1600 NEGATIVE

1625 NEGATIVE

Reference

(NEGATIVE)

(NEGATIVE)

(NEGATIVE)

(NEGATIVE)

CARE.CMC

Units

U #: M002240601

REG: 06/05/07

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