Consent Form Hiv Test (Page 24 of 42) in pdf

Instruction Guide for HIV Testing/Counseling

March 11, 2008

Purpose: These guidelines are designed to assist in the HIV Testing/Counseling and processing of all HIV orders.

It is important to follow these guidelines set by the Department of Health and adopted by Florida State Hospital.

You must be a certified HIV Counselor or licensed physician in order to provide the pre-test or post-test counseling.

Process:

The medical doctor/advanced registered nurse practitioner writes an order in the medical record for HIV testing;

however, this order is not routine for all admissions. In addition, a separate order for HIV testing must be entered

into the laboratory information system. Pre-test HIV counseling is a pre-requisite to all HIV orders.

A certified HIV Counselor must meet with the resident to complete the HIV Consent form (DH 1818) and DH Form

1628, to include documentation of all demographics, HIV history, and risk factors. The consent form remains in the

medical record; the lab does not need a copy. Once this pre-test counseling is complete, an order gets placed in

the laboratory information system. The completed DH Form 1628 must be provided to the laboratory technologist at

the time of the collection; otherwise, the order will be cancelled.

Once the FSH Laboratory receives the results from the Department of Health State Laboratory, a “Results Packet”

will be compiled. The lab will send the Unit Nurse Manager the “Results Packet”, document when the packet was

sent out and to whom it was sent and forward this information to the Registered Nurse Consultant –Infection

Control, in Quality Assessment and Planning. The “Results Packet” will consist of the three attached forms: pages 1

and 2 are carbon copies (labeled “Test Site Copy” and “Post-Test Documentation Form”, these are the official

documents sent by the Department of Health) and the third page is the official FSH Clinical Lab Results page.

The Unit Nurse Manager will be responsible for distributing the “Results Packet” to a HIV Counselor, preferably the

counselor who completed the pre-test counseling. The Nurse Manager will document on a tracking form which HIV

Counselor the “Results Packet” was distributed to.

Once the HIV Counselor receives the “Results Packet”, the counselor must keep the carbon copied pages together

and complete the required documentation. Please note that for the carbon copy to be visibly read the counselor

must use a ball point pen on a firm, flat surface and bear down on the carbon copy in order for the carbon to copy.

The boxed “Post Test Date” area must be bubbled in. The counselor must document his/her name.

The medical doctor may provide post-test counseling, but must follow the same procedure as the Certified HIV

Counselor regarding documentation.

After completing the required post-test counseling documentation, the HIV Counselor should separate pages one

and two of the carbon copies received from the Department of Health: page 1 labeled “Test Site Copy” and the FSH

Clinical Lab Results page must remain in the official medical record. Page 2 of the carbon copy, labeled “HIV

POST-TEST DOCUMENTATION FORM”, must be sent to the Registered Nurse Consultant - Infection Control in

Quality Assessment and Planning within 10 days of departure of this “Results Packet” from the lab. With in 30 days

the Registered Nurse Consultant – Infection Control must mail the HIV Post-test Documentation Form to the

Department of Health, Bureau of HIV/AIDS, 4052 Bald Cypress Way, BIN A09, Tallahassee, FL 32399-1715.

Attachment 5

Page 4 of 4

Operating Procedure 153-31

Consent Form Hiv Test Page 24