URS PREVENTION SERVICES COUNSELING, TESTING & PARTNER NOTIFICATION 02/10/06 Page 1 of 1
* CLIENTS NAME: * LAST
* FIRST
POST-TEST NEGATIVE ENCOUNTER FORM
* ID:
Middle
* STAFF: Xavior R. Ford
* ACTUAL DATE:
/ / MONTH
* PROGRAM: WBA
Appointment:
01 Radiology Dept. Agency
YEAR
Next Scheduled
/ / Month
* SERVICE SITE: Mobile Unit Location:
DAY
02 Laboratory
03 Hospital Based Visit
04 Home Based Visit
06 Mental Health Clinic
Day
07 On-Site
Year
08 Other Site, This
99 Other
* ENCOUNTER TYPE: 01 PRE-TEST COUNSELING WITHOUT HIV TESTING
ACTIVITIES:
* SERVICE(S) PROVIDED: 0001 PRE-TEST COUNSELING WITHOUT HIV RAPID TEST 0032 PRE-TEST COUNSELING WITHOUT HIV STANDARD TESTING
DEMONSTRATION OF: 31 Condom / Barrier Use 57 Decision Making
02 PRE-TEST COUNSELING WITH HIV TESTING
0030 CLIENT DID NOT RETURN FOR HIV POSITIVE TEST RESULT
58 Disclosure of HIV Status 32 IDU Risk Reduction
DISTRIBUTION OF:
✘ 87 Educational Materials 83 Female Condoms 86 Lubricants
✘ 82 Male Condoms
0031 CLIENT DID NOT RETURN FOR HIV NEGATIVE TEST RESULT
56 Negotiation / Communication
90 Other
0032 PRE-TEST COUNSELING WITH HIV STANDARD TESTING
61 Other
88 Referral Lists
60 Partner Notification
✘ 0033 PRE-TEST COUNSELING WITH RAPID HIV TEST
59 Providing Preventive Services
0034 CONFIRMATORY TEST ADMINISTERED
89 Role Model Stories
✘ 84 Safe Sex Kits 85 Safer Injection / Bleach Kits
DISCUSSION OF: 03 POST-TEST COUNSELING, NEGATIVE / INDETERMINATE RESULT
✘ 0001 POST-TEST COUNSELING, RAPID TEST NEGATIVE 0002 POST-TEST COUNSELING, STANDARD TEST NEGATIVE 0003 POST-TEST COUNSELING, CONFIRMATORY TEST NEGATIVE 0004 POST-TEST COUNSELING, CONFIRMATORY TEST INDETERMINATE 0005 POST-TEST COUNSELING, RAPID TEST INDETERMINATE 0006 POST-TEST COUNSELING, STANDARD TEST INDETERMINATE 0011 NEED FOR S / PN DISCUSSED
INFORMATION ON: 16 Abstinence / Postpone Sex 20 Alcohol And Drug Prevention
53 Alcohol And Drug Prevention
74 Availability of Partner Notif. & Ref. Srvs.
✘ 42 Availability of HIV STD C & T ✘ 45 Availability of Medical Services
76 Availability of Medical Services 75 Availability of Social Services 77 Condom / Barrier Use 79 Decision Making 14 Disclosure of HIV Status
04 POST-TEST COUNSELING, HIV + TEST RESULT / RETURN VISIT
0001 POST-TEST COUNSELING, POSITIVE CONFIRMATORY TEST RESULT 0002 POST-TEST COUNSELING, POSITIVE STANDARD TEST RESULT 0011 NEED FOR S / PN DISCUSSED
0014 S / PN IDENTIFICATION INFORMATION GATHERED 0015 PNAP / CNAP / OTHER S / PN SERVICE CALLED ON BEHALF OF CLIENT 0016 PNAP / CNAP / OTHER S / PN SERVICE APPOINTMENT SCHEDULED 0017 ON-SITE PNAP / CNAP / OTHER S / PN SERVICE PROVIDED TO CLIENT 0018 CLIENT REQUESTS PROVIDER TO PARTICIPATE IN S / PN
0020 NO SPOUSE(S) / PARTNER(S) 0021 NOTIFICATION PROCESS NOT RESOLVED 0022 CLIENT REFUSED S / PN SERVICES 0023 DOMESTIC VIOLENCE INDICATED
New York State Department of Health, AIDS Institute, Systems Development
✘ 12 HIV Testing ✘ 17 HIV / AIDS Transmission 11 IDU Risk Reduction
0013 PNAP / CNAP / OTHER S / PN REFERRAL INFORMATION PROVIDED
0019 CLIENT WILL SELF-NOTIFY
70 HIV Medication Therapy Adherence
71 IDU Risk Free Behavior
0012 EDUCATION ON SELF NOTIFICATION PROVIDED
23 Abstinence / Postpone Sex
✘ 73 Availability of HIV STD C & T
✘ 72 Living With HIV / AIDS 78 Negotiation / Communication 81 Other
✘ 13 Other STD 15 Partner Notification
✘ 80 Providing Preventive Services ✘ 19 Sexual Health ✘ 10 Sexual Risk Reduction 21 TB 18 Viral Hepatitis OTHER:
✘ 40 Elicit Partners 37 HIV Testing 93 HIV Testing History Survey
26 Availability of PCRS 44 Availability of Social Services
✘ 29 Condom / Barrier Use 47 Decision Making 48 Disclosure of HIV Status 52 HIV Medication Therapy Adherence
✘ 50 HIV Testing ✘ 22 HIV / AIDS Transmission 95 IDU Risk Free Behavior 28 IDU Risk Reduction 43 Living With HIV / AIDS 46 Negotiation / Communication 55 Other
✘ 24 Other STD 51 Partner Notification 49 Providing Preventive Services 54 Sexual Health 27 Sexual Risk Reduction 30 TB 25 Viral Hepatitis PRACTICE OF: 62 Condom / Barrier Use 65 Decision Making 66 Disclosure of HIV Status
41 Notification of Exposure
* BOLD FIELDS MUST BE COMPLETED
January 2006 (URS v4.3b)