Consent Form Hiv Test Page 42
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42Instructions for Form 1628 HIV Lab Request
Please complete numbered blanks with indicated information
1)
Site Address:
Florida State Hospital, Bldg. 1238, Palm Lane, Chattahoochee, Fla.
32324-1000
2)
Site Number 10-210
3)
Local Use : Put Resident number
4)
Counselor Number – Put first initial, last name of HIV Counselor
5)
Pretest Counsel Date: _______________ and consent signed yes with date.
NOTE: Lab tests for HIV ARE NOT to be entered into the Laboratory Computer
(CLINILAB)
until pretest counseling and consent date are obtained. The Lab will NOT
draw blood if the pretest counseling date and the consent signed date with yes is not
completed.
6)
Check type of test to be done. Put an X in block 1 for blood.
7)
Resident’s l
ast name, first name, MI.
8)
Phone – Home Unit Main Number with area code.
9)
Address: Fl
orida State Hospital, P.O. Box 1000, Chattahoochee, Fla. 32324-1000
10) Date of Birth:
11) SS#:
12) Unit Numbe
r and Ward
13)
Medicaid Number (if pt. has one)
Complete all sections as completely as possible.
Units – make a copy of the lab request for the resident’s medical record. Place the co
py with
the informed consent un
der the Legal Section of the medical record.
The entire Lab request goes to the Lab with the specimen.
Label lab tube with resident’s full name, medical record #, collector’s initials, date and time.
Documentation-Pre and post test HIV Counseling is to be documented in the Nursing Progress
Note and the Immunization Record (Form 13), page 2, Education section
7/30/2008
Attachment 11
Page 4 of 4
Operating Procedure 153-31
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal