Blank Bureau of Prisons HIV counseling form with staff signature dated July 9, 2015

EFTA00139132¶

BP-A0489 JUN 10¶

HIV COUNSELING DOCUMENTATION¶

U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS¶

Directions:¶

Use the following criteria to counsel the patient who is tested for the HIV antibody. Check off each item as they are discussed. Write NA beside any item that is inappropriate to the situation. Thereverse side of this form will be utilized to document seronegative and inconclusive test result. Then file in the patient’s record, documenting in progress notes that counseling was completed.¶

PRETEST:¶

1. Explain purpose of session.

2. Explain confidentiality.

3. Explain HIV antibody test.

a. What HIV is¶

c. Test Procedure¶

\_\_\_d.

Meaning of test results

e. Inability of detecting early infection (false negatives)¶

f. Potential need for additional testing¶

g. Significance of a positive test.¶

4. List risk factors/clinical signs: (check all that apply)¶

a. Injecting drug use, sharing drug or tattoo equipment¶

b. Unprotected or multiple sex partners¶

d. Clinical s/s: fever or illness of unknown cause, symptoms of AIDS opportunistic infections.¶

e. Exposure: recent occupational or non-occupational exposure/incident.¶

| | |¶

| :--- | :--- |¶

| f. | Pregnant female |¶

5. Obtain informed consent (when applicable).

6. Risk Reduction Behaviors. Educational material given.

7. Patient Reactions/Comments.

8. Explain how the patient will be notified of the result.

The above information has been explained to me in a language I can understand.¶

Signature of Inmate	Signature of Staff Counselor
Date: 7/9/15 76318-054

Inmate Name:¶

Register No.:¶

Institution:¶

File in the Medical Record: Section 6.¶

SDNY_00017¶

Prescribed by P6190¶

Replaces BP-S489.061 of APR.¶