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CTS HIV Test Request Forms Training. Overview. Introduction Explore new form Practice. Introduction. New CDC requirements – standard set of data from public testing sites PEMS (Program Evaluation and Monitoring System) Implementation: May 1, 2009. Form Orientation.

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overview
Overview
  • Introduction
  • Explore new form
  • Practice
introduction
Introduction
  • New CDC requirements – standard set of data from public testing sites
  • PEMS (Program Evaluation and Monitoring System)
  • Implementation: May 1, 2009
form orientation
Form Orientation
  • Page 1: Patient, specimen, requested testing and risk information
  • Page 1: Sent to OSPHL
  • Page 2: Carbon copy of page 1 for chart/folder
  • Page 2: Detailed instructions on back
  • Page 3: Post-test disposition
  • Page 3: Detailed instructions on back
what s new
What’s New
  • Test History section
  • Reworded Risk Reduction and Referrals section
  • Reworded Risk and Exposures section
mailing address test form id
Mailing Address & Test Form ID
  • Mailing address:
    • Send forms and specimens to the address listed
  • Test Form ID:
    • Ten digits; no dashes.
    • Same number that is on labels
    • Reference the test form ID on specimens and corresponding forms, if necessary
patient information
Patient Information

1/15/1975

Multnomah

OR

97232

34

1/15/2010

x

Must be completed in its entirety!

Patient ID/Chart Number is for use with your records – you should also complete this box if you have to assign the client a unique identifier other than DOB.

Incomplete patient information will delay the processing of the test.

submitter information section
Site ID (4 or 5 digit) and submitter code (6 digits) is mandatory! Missing info will delay the processing of your test.

Sites have the option of leaving the rest of this section blank if registered with OSPHD HIV Prevention Program

Submitter Information Section

000000

1111

non rapid specimen information
Non-Rapid Specimen Information

x

  • Fill out this section for non-rapid testing
  • Identify the specimen source being submitted
  • Specimens that fall into the “other” category – check with lab to make sure they can process
non rapid tests requested
Non-Rapid Tests Requested

x

Common Error Alert: Remember to check either confidential or anonymous!

x

  • Indicate if the test is confidential or anonymous.
    • If confidential, write patient information on bottom section of carbon copy.
  • Indicate Non-Rapid Test Requested:
    • Screen (EIA and western blot if needed).
    • Western Blot only (likely to be requested rarely, but may be used to confirm a previous result or conduct follow-up testing of a previously indeterminate test).
non rapid tests requested1
Non-Rapid Tests Requested

x

x

090200000

  • Confirmation of preliminary positive (EIA and western blot regardless of EIA result).
    • If the rapid testing was done at a separate encounter, if possible, indicate the form ID for that rapid test by indicating the previous test form ID on the line next to this selection.
    • If the rapid test was done the same encounter or if previous test form ID is not known, leave the line blank.
  • Follow-up of invalid rapid test (EIA and western blot if needed).
  • If other is selected indicate preferred test. Confirm with lab prior to ordering.
test history
Test History

Common Error Alert: Remember to record responses for “Previous HIV Testing”, if client answers “Yes” record appropriate response for “last test was”. In addition, if client answers yes, attempt to record previous testing date.

x

x

x

  • Ask client and indicate whether or not a previous HIV test was conducted and the result of that test if known
  • Indicate month (mm) and year (yyyy) of known previous test. If month unknown, enter year and leave month blank. If year unknown, ask client to estimate the year
rapid testing
Rapid Testing
  • Complete this section only if HIV Rapid Test is performed at today’s encounter
  • Indicate if the test is confidential or anonymous.
  • If no blood or oral specimen will be sent with test form to the laboratory (i.e. rapid test is negative) select ‘DATA ONLY FORM’

x

x

x

x

x

Common Error Alert: Remember to check either confidential or anonymous!

Common Error Alert: Remember to complete ALL sections!

client race ethnicity
Client Race & Ethnicity
  • Ask client to identify their race and ethnicity.

x

x

Common Error Alert: remember to check client identified race/ethnicity OR “don’t know” or “declined to answer”.

risk reduction referrals
Risk Reduction & Referrals
  • Indicate whether you discussed risk reduction strategies with the client and if not, why
    • Notice N/A options
  • Indicate whether HIV positive or negative high-risk client was referred to HIV Prevention Services:
    • Substance abuse treatment
    • Counseling
    • HCV Testing
    • Or any other explicit referral aimed at risk reduction
    • Notice N/A options

Common Error Alert: remember to complete this section in its entirety!

x

x

risk exposures
Risk/Exposures
  • Do not read this section as a checklist.
  • Report affirmative answers, if and only if, the client is confident of the response

x

x

x

x

x

slide18
Common Errors:

Omitting the frequency for use of condoms/sharing of syringes and injection equipment.

x

x

Leaving the Risk and Exposures Section blank. If you are leaving this section blank, be sure to mark off one of the following options:

labels
Labels
  • Each form will have 10 labels
  • 8 with just the form ID
  • 2 with both the form ID and an extra line for the 2nd identifier
  • Use one of the labels with extra line, write the 2nd identifier & place on the specimen prior to submitting
  • If your specimen doesn’t have a second identifier, it will NOT be processed.
patient identifier
Patient Identifier
  • Needs to be unique
  • The lab suggests that sites implement a patient ID number that is composed of the date and the order of the client
  • For example, the patient ID for forth client seen on 12/31/2008 could be listed as 12310804
  • You may use a different formula to develop an identifier but, be sure that the identifier is unique
documenting informed consent
Documenting Informed Consent
  • Oregon ORSs require that non licensed health care providers/non licensed health care facilities document informed consent.
  • Model consent form can be found on the web: http://www.oregon.gov/DHS/ph/hiv/informedconsent.shtml
rapid test with non rapid same day confirmatory test
Use one form for both tests.

Fill out:

Non-rapid specimen information

Non-rapid tests requested

Rapid Testing

Rapid test with non-rapid same day confirmatory test
anonymous rapid test followed by a confidential non rapid confirmatory
Anonymous Test

Confidential Test

Anonymous rapid test followed by a confidential non-rapid confirmatory
  • You will need to use two forms: 1-Anonymous test

1-Confidential test

  • Place the rapid test form ID (test #) from the anonymous form on the line “’confirm. of prelim. pos. rapid test” located in the non-rapid test requested section of the confidential form
  • Risk/exposures information must be reported either on the anonymous form or the confidential form, not both
confidential rapid test followed by an anonymous non rapid confirmatory
Confidential Test

Anonymous Test

Confidential rapid test followed by an anonymous non-rapid confirmatory
  • You will need to use two forms: 1-Confidential test 1-Anonymous
  • Place the rapid test form ID (test #) from the confidential form on the line “’confirm. of prelim. pos. rapid” located in the non-rapid test requested section of the anonymous form.
  • Risk/exposures information must be reported either on the anonymous form or the confidential form, not both.
dual rapid testing
Rapid Test

Submitted Rapid Test

Dual Rapid Testing
  • Some testing sites occasionally conduct more than one rapid test in the same encounter.
    • In the event that two rapid tests are conducted at the same session, record both rapid tests on separate forms for site recording purposes.
    • Indicate the test form ID for the other rapid test below the rapid testing section.
  • Submit the form to the laboratory which drives the decision about whether to seek confirmatory testing (next slide)
post test disposition form
Mailing Address

Referrals

Everyone

Testing Follow-up

Referrals

Females

Post-Test Disposition Form
  • Form should only be completed and submitted for clients with positive non-rapid tests
  • Do not submit this form if non-rapid test is negative
non rapid confirmatory testing follow up
Non-Rapid/Confirmatory Testing Follow-up
  • Only submit for clients with positive non-rapid tests
  • Non-Rapid/ Confirmatory Testing Follow-Up Section:
    • Indicate whether results were provided to the client and if not, why
    • Indicate the date of return visit
referrals
Referrals
  • Everyone:
    • Indicate if referred to HIV medical care and whether an appointment was scheduled
    • Indicate whether or not client was referred to Partner Services and if Partner Services had been provided
  • Females Only:
    • Indicate whether client is currently pregnant and if they are currently in prenatal care
    • If client is not in prenatal care, indicate whether client was referred to prenatal care and if appointment was scheduled
submitting post test disposition form
Submitting Post-Test Disposition Form
  • For positive non-rapid tests ONLY
  • Complete and return within 30 days
  • Mailing Address:
    • Oregon State Public Health Laboratory PO Box 275 Portland, OR 97207-0275
cts hiv test request form

CTS HIV Test Request Form

Agency, Client, Test, Referral and Risk/Exposure Information

let s practice1
Let’s Practice….
  • Submitter Information
    • Site ID: 11111
    • Submitter Code: 001122
  • Client Race & Ethnicity
    • Declined to answer both
  • Reason for Test
    • Asymptomatic, self initiated
  • Patient Information
    • Refuses to give DOB
    • Washington County, OR 99999
    • Date of Collection: today’s date
    • Identifies as Male
let s practice2
Let’s Practice….
  • Test History
    • Previously tested in 2006; results unknown
  • Rapid Testing
    • Testing confidentially – his name is Brad M. Smith
    • Oral specimen taken
    • Preliminary positive
    • Results provided and confirmatory specimen collected
  • Non-Rapid Specimen Information
    • Blood draw taken
    • Unique ID: Today’s date + client number (10)
  • Non-Rapid Tests Requested
    • Testing confidentially
let s practice3
Let’s Practice….
  • Risk/Exposures
    • Brad has had anal sex with 3 men and no women in the last 12 months, he uses condoms sometimes
    • Brad has not has sex in exchange for money, drugs or anything of value in the last 12 months but has in his lifetime
    • Brad has had anonymous sex in the last 12 months
    • Brad does not know if he has ever had sex with a person who injects drugs or that is HIV positive
    • Brad has used injection drugs in the last 12 months; he has never shared needles/injection equipment
  • Risk Reduction & Referrals
    • You discussed risk reduction strategies with Brad
    • Brad declined offer for HIV prevention services
slide37

Washington

OR

99999

001122

11111

25

Today’s date

Name and phone number of person administering test

02

2006

let s practice4
Let’s Practice…
  • A confirmatory test indicates Brad is HIV+
  • He was given his results on 06/17/08
  • Brad accepted a referral to medical care, but has not scheduled an appointment yet
  • Brad was referred to partner services and partner services were provided
check your work
Check your work…

06 17 2008

04

04

questions comments concerns cesssa karson@state or us 971 673 0150
Questions, Comments, Concerns?cesssa.karson@state.or.us971-673-0150