Atch_3_-_MMP_2017_Paper_Abstraction_Form_v1.0.pdf

Tracking and Demographics PARID _ _ _ _ _ _ _ _ _ _ _ _

MMP Medical Record Abstraction Form-2017 Data Collection Cycle

OPTIONAL- FOR LOCAL USE ONLY-DO NOT ENTER IN DISCOVERE®

Participant ID Facility ID

Medical record number

Patient Name

First: Last:

Patient Address

Street:

City: State: Zip Code: -

Physician name

First: Last:

Time Block Reference Dates for Diagnosis, Medications, MAC and PCP Prophylaxis

Time Block Start of time block (mm/dd/yyyy) End of time block (mm/dd/yyyy)

Started/ongoing first 6 months (Equivalent to Start of observation period)

Started/ongoing 7-12 months

Started/ongoing 13-18 months

Started/ongoing 19-24 months (Equivalent to End of observation period)

Sections Completed on This Participant

Section Number of Forms Completed Lab Section Number of Forms

Completed

Demographics Are all elements completed?

Y/N

CBC

Chemistry

Outpatient Encounters Other Chemistry

Inpatient Encounters Lipids

Diagnosis Urine

Medications HIV

Procedures Serology

Prophylaxis STI Screening

Pregnancy Mammogram/Pap

Resistance Data TB Screening

Tracking and Demographics PARID _ _ _ _ _ _ _ _ _ _ _ _

DEMOGRAPHICS

PARID

Abstractor ID:

Facility ID (eight digits: Project Area FIPS code + Facility ID)

Facility location (city or state) from which medical record was obtained:_____________________________________

(If International, specify city/country)

Does the facility receive Ryan White Care funding?

Yes No Unknown

Start of Observation Period

/ / mm/dd/yyyy

End of Observation Period

/ / mm/dd/yyyy

Did the participant receive HIV medical care at this facility during the 2 years prior to the interview date?

Yes Go to DOB No Complete as much demographic information as available ONLY in the medical record

Date of Birth (month) Date of Birth (year)

Gender:

Male

Female

Transgender

Transgender (female to male)

Transgender (male to female)

Not Documented

Race (select all that apply)

American Indian/Alaska Native

Asian

Black/African American

Native Hawaiian/Other Pacific Islander

White

Not Documented

Hispanic/Latino Ethnicity or Spanish Origin

Yes

No

Not Documented

Insurance (select all that apply):

ADAP Medicare Medicaid Ryan White Tricare/CHAMPUS VA coverage Private None/self-pay

City/county/state/other publicly funded Other insurance ________________________________ Not Documented

HIV Information

Is date of first HIV diagnosis documented in the medical record?

YesEnter date of first HIV diagnosis

NoGo to lowest CD4

Date of first HIV diagnosis mm/dd/yyyy

Lowest CD4 count since HIV diagnosis

Date of lowest CD4 count / / mm/dd/yyyy Date of lowest CD4 Not Documented

What is the source of the lowest CD4 count? Flow sheet review Provider progress note based on patient self-report

Provider progress note based on lab report Laboratory report review Other

Abstraction Complete? Yes No javascript:showHistory('D35DE06061C43926E0408C9FCA3063D4',null,null,'') javascript:showHistory('D3077A79D51DAB9FE0408C9FCA301E92',null,null,'') javascript:showHistory('D35DE06061D13926E0408C9FCA3063D4',null,null,'') javascript:showHistory('D35DE06061D33926E0408C9FCA3063D4',null,null,'')

Outpatient Encounters PARID _ _ _ _ _ _ _ _ _ _ _ _

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Unknown

Specify provider type (See list in Abstraction Manual Appendix)

Were any vital signs documented during the encounter?

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Yes No/Not Documented

Weight lbs kgs ND

Weight Not Documented

Height (ft) (in)

Height Not Documented

Blood Pressure

Systolic Diastolic

Blood Pressure Not Documented

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Specify provider type (See list in appendix )

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Systolic Diastolic

Blood Pressure Not Documented

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Systolic Diastolic

Blood Pressure Not Documented javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'')

Outpatient Encounters PARID _ _ _ _ _ _ _ _ _ _ _ _

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Systolic Diastolic

Blood Pressure Not Documented

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Systolic Diastolic

Blood Pressure Not Documented

OUTPATIENT ENCOUNTERS

Encounter Date mm/dd/yyyy

How did the encounter take place? With whom did the encounter take place?

In person Telephone Email

Other, specify ____________ ND

MD

PA

DO

NP

Other

Unknown

Did the encounter take place with a known HIV provider?

Yes

No For all responses, go to specify provider type

Yes No

One or more physical exam findings documented during encounter?

Yes No

Antiretroviral therapy prescribed, refilled or continued during encounter?

Systolic Diastolic

Blood Pressure Not Documented javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC9FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC4FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC5FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC6FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC7FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'') javascript:showHistory('D37D75535CC8FB94E0408C9FCA3030C2',null,null,'')

Hospitalizations and Procedures PARID _ _ _ _ _ _ _ _ _ _ _ _

INPATIENT HOSPITALIZATIONS

Was the patient hospitalized during the observation period? Yes No/Not Documented Go to Diagnosis Section

Inpatient Admission Date

/ / (mm/dd/yyyy) Admission date Not Documented

Inpatient Discharge Date

/ / (mm/dd/yyyy) Discharge date Not Documented

Discharge Diagnosis (list all that are documented):

Was the patient hospitalized during the observation period? Yes No/NDGo to Diagnosis Section

Inpatient Admission Date

/ / (mm/dd/yyyy) Admission date Not Documented Inpatient Discharge Date

/ / (mm/dd/yyyy) Discharge date Not Documented

Discharge Diagnosis (list all that are documented):

Was the patient hospitalized during the observation period? Yes No/NDGo to Diagnosis Section

Inpatient Admission Date

/ / (mm/dd/yyyy) Admission date Not Documented Inpatient Discharge Date

/ / (mm/dd/yyyy) Discharge date Not Documented

Discharge Diagnosis (list all that are documented):

javascript:showHistory('D37608ACB2BBDF5DE0408C9FCA3071C5',null,null,'')

Hospitalizations and Procedures PARID _ _ _ _ _ _ _ _ _ _ _ _

PROCEDURES

Date of Procedure / / mm/dd/yyyy

Amputation (specify details)______________________

Angioplasty

Cardiac bypass surgery (specify # of vessels) _________

Cardiac procedure, other (specify details)

Contraception: Implantable rod (Implanon)

Contraception: Sterilization implant (Essure)

Heart valve surgery (specify valve) _________________

Hysterectomy

Solid organ transplant (specify)

Anal condyloma removal

Bone marrow transplant (specify) _________________

Cardiac catheterization

Cardiac stent placement

Contraception: Intrauterine device (IUD) placement

Contraception: Tubal ligation

Hernia repair

Renal dialysis

Surgical procedure (specify)

Vasectomy

PROCEDURES

Date of Procedure / / mm/dd/yyyy

Amputation (specify details)______________________

Angioplasty

Cardiac bypass surgery (specify # of vessels) _________

Cardiac procedure, other (specify details)

Contraception: Implantable rod (Implanon)

Contraception: Sterilization implant (Essure)

Heart valve surgery (specify valve) _________________

Hysterectomy

Anal condyloma removal)

Cardiac catheterization

Cardiac stent placement

Contraception: Intrauterine device (IUD) placement

Contraception: Tubal ligation

Hernia repair

Renal dialysis

Surgical procedure (specify)

Vasectomy

PROCEDURES

Date of Procedure / / mm/dd/yyyy

Amputation (specify details)______________________

Angioplasty

Cardiac bypass surgery (specify # of vessels) _________

Cardiac procedure, other (specify details)

Contraception: Implantable rod (Implanon)

Contraception: Sterilization implant (Essure)

Heart valve surgery (specify valve) _________________

Hysterectomy

Anal condyloma removal)

Cardiac catheterization

Cardiac stent placement

Contraception: Intrauterine device (IUD) placement

Contraception: Tubal ligation

Hernia repair

Renal dialysis

Surgical procedure (specify)

Vasectomy

Diagnosis and Medications PARID _ _ _ _ _ _ _ _ _ _ _ _

DIAGNOSIS

Diagnosis

Beginning of month 1

(start of observation pd.)

mm/dd/yyyy

Beginning of month 7

Beginning of month 13

Beginning of month 19

Started/ongoing first 6 months

Started/ongoing 7-12 months

Started/ongoing 13-18 months

Started/ongoing 19-24 months

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Yes

No/Not Documented

Diagnosis and Medications PARID _ _ _ _ _ _ _ _ _ _ _ _

MEDICATIONS

Medication Route*

(select one):

Frequency†

(ARV only)

Beginning of month 1 (start of observation pd.)

mm/dd/yyyy month 7 month 13

Beginning of month 19 mm/dd/yyyy

Started/ongoing first 6 months

Started/ongoing

7-12 months

Started/ongoing

13-18 months

Started/ongoing

19-24 months

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

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Yes

No/Not Doc

Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

No/Not Doc

Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

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Yes

No/Not Doc

* PO-by mouth/orally, IV-intravenous, IM-intramuscular, ID-intradermal, SQ-subcutaneous, INH-inhalational, TD-transdermal, per rectum, per vagina, injection, sublingual, Other (specify), Not documented

†QD-once daily, BID-twice daily, TID-3 times daily, QID-4 times daily, QAM-every morning, QPM-every evening, QHS-every night before sleep ,Q4H-every 4 hours, Q6H-every 6 hours, Q8H-every 8 hours, Q12H-every 12 hours, QOD-every other day, Q2 days-every 2 days, QWK-once a week, BIW-twice a week, TIW-three times/week, Once, Other (specify), Not documented

MAC & PCP Prophylaxis/Influenza Vaccination and TB Screening/Mammogram/Pap Smear PARID _ _ _ _ _ _ _ _ _ _ _ _

PROPHYLAXIS–MAC

MAC prophylaxis administered?

YesGo to MAC Medication

No/Not DocumentedGo to PCP

MAC medication:

Azithromycin (Zithromax) 600 mg po twice weekly Azithromycin (Zithromax) 1200 mg po weekly

Azithromycin (Zithromax) 1200 mg weekly + Rifabutin 300 mg po daily

Clarithromycin (Biaxin) 500 mg po twice daily Rifabutin (Mycobutin) 300 mg po daily

Other MAC prophylaxis (specify drug name & dosage) ___________________________________________________________

Beginning of month 1 (start of observation pd.)

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 7

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 13

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 19

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Started/ongoing first 6 months Started/ongoing 7-12 months Started/ongoing 13-18 months Started/ongoing 19-24 months

Yes No/Not Documented Yes No/Not Documented Yes No/Not Documented Yes No/Not Documented

PROPHYLAXIS–PCP

PCP prophylaxis administered?

YesGo to PCP Medication

No/Not DocumentedGo to FLU

PCP medication:

Trimethoprim/Sulfamethoxazole(Bactrim,Septra,Cotrim) one double strength tablet po daily

Trimethoprim/Sulfamethoxazole(Bactrim,Septra,Cotrim) one single strength tablet po daily

Trimethoprim/Sulfamethoxazole(Bactrim,Septra,Cotrim) one double strength tablet po 3 times/week

Dapsone 100 mg po daily Dapsone 50 mg twice daily Atovaquone (Mepron) 1500 mg po daily

Atovaquone (Mepron) 1500 mg + pyrimethamine 25 mg + folinic acid (Leucovorin) 10 mg po daily

Aerosolized Pentamidine (Pentam) 300 mg inhalation monthly

Dapsone 200 mg + pyrimethamine 75 mg + folinic acid (Leucovorin) 25 mg weekly

Dapsone 50 mg daily + pyrimethamine 50 mg weekly + folinic acid (Leucovorin) 25 mg weekly

Other PCP prophylaxis (specify drug name & dosage) ______________________________________________________________

Beginning of month 1 (start of observation pd.)

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 7

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 13

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Beginning of month 19

_ _/_ _ /_ _ _ _ mm/dd/yyyy

Started/ongoing first 6 months Started/ongoing 7-12 months Started/ongoing 13-18 months Started/ongoing 19-24 months

Yes No/Not Documented Yes No/Not Documented Yes No/Not Documented Yes No/Not Documented

INFLUENZA VACCINATION

Influenza vaccine administered? YesEnter ALL date(s) vaccine administered during observation period NoGo to TB Not DocumentedGo to TB

What date was the influenza vaccine administered?

mm/dd/yyyy

What date was the influenza vaccine administered?

mm/dd/yyyy

What date was the influenza vaccine administered?

MAC & PCP Prophylaxis/Influenza Vaccination and TB Screening/Mammogram/Pap Smear PARID _ _ _ _ _ _ _ _ _ _ _ _

TUBERCULOSIS SCREENING

Was a PPD placed?

Yes

No/ND Go to IGRA (if applicable)

Was the PPD read?

Yes

No/ND Go to IGRA (if applicable)

Date PPD read

Date PPD read Not Documented

PPD Result

Negative Positive 0 mm 1mm 2mm

3mm 4mm ≥5mm Not documented

Interferon Gamma Release Assay (IGRA)

Collection date / /

IGRA test type

QuantiFERON-TB Gold Test

T-Spot Test Not Documented

IGRA result

Positive

Indeterminate

Negative

Not documented

Borderline

MAMMOGRAM

Mammogram Screening date

/ / (mm/dd/yyyy)

Mammogram result:

Normal Abnormal Not Documented

PAP SMEAR #1

Pap Screening Date: / / (mm/dd/yyyy) Pap source: Cervix Anus Vaginal Not Documented

Pap result:

Negative for intraepithelial lesion or malignancy ASC-US* ASC-H† LSIL (LGSIL)§ HSIL (HGSIL)‡ Squamous cell carcinoma

Atypical glandular cells (AGUS) Atypical glandular cells-favor neoplastic Carcinoma in situ Adenocarcinoma

Other (specify) ________________________________________________________________ Not documented

PAP SMEAR #2

Pap Smear Date: / / (mm/dd/yyyy) Pap source: Cervix Anus Vaginal Not Documented

Pap result:

Negative for intraepithelial lesion or malignancy ASC-US* ASC-H† LSIL (LGSIL)§ HSIL (HGSIL)‡ Squamous cell carcinoma

Atypical glandular cells (AGUS) Atypical glandular cells-favor neoplastic Carcinoma in situ Adenocarcinoma

Other (specify) ________________________________________________________________ Not documented

*ASC-US –atypical cells of undetermined significance; †ASC-H –atypical cells, cannot rule out high grade lesion; §LSIL –low grade squamous intraepithelial lesions;

‡HSIL –high grade squamous intraepithelial lesions

Pregnancy PARID _ _ _ _ _ _ _ _ _ _ _ _

PREGNANCY #1

Pregnant during the obs period?

Yes No/Not documented Go to Labs Number of pregnancies (Range 1-10)

Outcome of pregnancy # 1

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #1 / / Date of outcome #1 Not Documented

PREGNANCY #2

Outcome of pregnancy # 2

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #2 / / Date of outcome #2 Not Documented

PREGNANCY #3

Outcome of pregnancy # 3

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #3 / / Date of outcome #3 Not Documented

Pregnancy PARID _ _ _ _ _ _ _ _ _ _ _ _

PREGNANCY #4

Outcome of pregnancy # 4

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #4 / / Date of outcome #4 Not Documented

PREGNANCY #5

Outcome of pregnancy # 5

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #5 / / Date of outcome #5 Not Documented

PREGNANCY #6

Outcome of pregnancy # 6

Elective surgical abortion

Elective medical abortion (RU486)

Intrauterine fetal death (enter delivery method)

Spontaneous abortion/miscarriage

Still pregnant (Date of outcome=end of obs period date)

Live birth(enter delivery method)

Not DocumentedGo to Labs

Delivery Method

Cesarean section (elective)

Cesarean section (non-elective)

Cesarean section (NOS)

Induced vaginal delivery

Spontaneous vaginal delivery

Not Documented

Date of outcome #6 / / Date of outcome #6 Not Documented

HIV Labs, CBC, Chemistry PARID _ _ _ _ _ _ _ _ _ _ _ _

CBC/CHEMISTRY/HIV LABS

Collection date / / (mm/dd/yyyy)

HIV Labs CD4 Count* CD4 Percent (%)

Viral load sign

< (less than) lower limit of detection or undetectable

> (greater than) or above upper limit of detection

= (equal to) or detectable

Viral load result Viral load units

Copies/ml x103 copies/ml

K copies/ml

Units/ml

Log copies /ml

Other ______________

Viral load Lower limit Viral load Upper limit

Other ____________

Not Documented

75,000

100,000

500,000

750,000

Other

1,000,000

2,000,000

5,000,000

6,000,000

Not documented

10,000,000

100,000,000

CBC

WBC count WBC Units x103/µl x103/mm3 x109/L Other______________ Unknown

Hemoglobin (Hb) result Hemoglobin Units g/dL g/L mmol/L Other_______________ Unknown

Platelet (Plt) count Platelet Units x103/µl x109/L cells/µl cells/CUMM Other____________________ Unknown

Mean Corpuscular Volume (MCV) result Neutrophil Count/% Neutrophil Units x103/ µl x106/ L x109/ L cells/ µl cells/CUMM

K/ µl K/CUMM % Other_________________ Unknown

CHEMISTRY

Fasting Lab? Yes No/Not Documented Glucose (Glu) Glu Units: mg/dL mmol/L Other_______ Unknown

Creatinine (Cr) Cr Units mg/dL µmol/L Other Unknown

Calcium (Ca) Ca Units mg/dL mmol/L mEq/L Other Unknown

AST AST Units IU/L U/L µKat/L Other Unknown ALT ALT Units IU/L U/L µKat/L Other Unknown

Albumin (Alb) Alb Units g/dL g /L U/L µmol /L Other

Total Bilirubin (Tb) Tb Units mg/dL µmol/L Other Unknown

*Equivalent CD4 count units: CELLS/µL, CELLS /MM3 , CELLS /MCL, CELLS/ MICROL, CELLS /UL, C/UL, /MCL, /UL, /MICROL, UL, MCL, #/UL, #/MICROL, CELLS/CMM, CELLS/CUMM, CU MM, CU.MM, CU/MM, PER CUMM, PER CMM, /CUMM, /CMM, /MM3, MM3, X10E6/L.

HIV Labs, CBC, Chemistry PARID _ _ _ _ _ _ _ _ _ _ _ _

CBC/CHEMISTRY/HIV LABS

Collection date / / (mm/dd/yyyy)

HIV Labs CD4 Count* CD4 Percent %

Viral load sign

< (less than) lower limit of detection or undetectable

> (greater than) or above upper limit of detection

= (equal to) or detectable

Viral load result Viral load units

Copies/ml

K copies/ml x103 copies/ml

Log copies/ml

Units/ml

Other ______________

VL Lower limit VL Upper limit

Other ____________

Not Documented

75,000

100,000

500,000

750,000

Other

1,000,000

2,000,000

5,000,000

6,000,000

Not documented

10,000,000

100,000,000

CBC

WBC count WBC Units x103/µl x103/mm3 x109/L Other _____________ Unknown

Hemoglobin (Hb) result Hemoglobin Units g/dL g/L mmol/L Other _____________ Unknown

Platelet (Plt) count Platelet Units x103/µl x109/µl cells/µl cells/CUMM Other _____________ Unknown

Mean Corpuscular Volume (MCV) result Neutrophil Count/% Neutrophil Units x103/ µl x106/L x109/L cells/ µl cells/CUMM

K/ µl K/CUMM % Other _____________ Unknown

CHEMISTRY

Fasting Lab? Yes No/Not Documented Glucose (Glu) Glu Units: mg/dL mmol/L Other_______ Unknown

Creatinine (Cr) Cr Units mg/dL µmol/L Other Unknown

Calcium (Ca) Ca Units mg/dL mmol/L mEq/L Other Unknown

AST

AST Units IU/L U/L µKat/L Other Unknown

ALT

ALT Units IU/L U/L µKat/L Other Unknown

Albumin (Alb) Alb Units g/dL g/L U/L µmol /L Other

Total Bilirubin (Tb) Tb Units mg/dL µmol/L Other Unknown

*Equivalent CD4 count units: CELLS/µL, CELLS /MM3 , CELLS /MCL, CELLS/ MICROL, CELLS /UL, C/UL, /MCL, /UL, /MICROL, UL, MCL, #/UL, #/MICROL, CELLS/CMM, CELLS/CUMM, CU MM, CU.MM, CU/MM, PER CUMM, PER CMM, /CUMM, /CMM, /MM3, MM3, X10E6/L.

Other Chemistry/Lipids/Urine/Toxoplasma/Hepatitis B and C PARID _ _ _ _ _ _ _ _ _ _ _ _

LIPIDS/OTHER CHEMISTRY/URINE LABS

Other Chemistry Collection date

/ / mm/dd/yyyy

Hemoglobin A1c (HgbA1c)

International Normalized Ratio (INR)

Intact Parathyroid Hormone (PTH ) PTH units mcU/L mIU/dL mU/L ng/dL ng/L ng/mL nmol/L pg/mL pmol/L U/mL µIU/mL µU/mL Other Unknown

Thyroid Stimulating Hormone (TSH) TSH units mcU/L mIU/dL mU/L ng/dL ng/L ng/mL nmol/L pg/mL pmol/L U/mL µIU/mL µU/mL Other Unknown

Total Testosterone Total testosterone units mcU/L mIU/dL mU/L ng/dL ng/L ng/mL nmol/L pg/mL pmol/L U/mL µIU/mL µU/mL Other Unknown

Vitamin D Total (25-hydroxyvitamin D total) Vitamin D total units mcU/L mIU/dL mU/L ng/dL ng/L ng/mL nmol/L pg/mL pmol/L U/mL µIU/mL µU/mL Other Unknown

Lipids # 1

Lipid Collection date #1 / / mm/dd/yyyy Fasting Lab? Yes No/Not Documented

Cholesterol Cholesterol units mg/dL mmol/L Other Unknown

HDL

HDL units mg/dL mmol/L Other Unknown

LDL

LDL units mg/dL mmol/L Other Unknown

Triglycerides (TG) TG units mg/dL mmol/L Other Unknown

Lipids # 2

Lipid Collection date #2 / / mm/dd/yyyy Fasting Lab? Yes No/Not Documented

Cholesterol Cholesterol units mg/dL mmol/L Other Unknown

HDL

HDL units mg/dL mmol/L Other Unknown

LDL

LDL mg/dL mmol/L Other Unknown

Triglycerides (TG) TG units mg/dL mmol/L Other Unknown

Urine Urine Collection date (mm/dd/yyyy )

Urine protein (numeric) units Urine protein (non-numeric) result

Urine protein (numeric) result g/dL mg/dL mg/24 hours mcg/mg mcg/g

Other mcg/mmol mg/g

Unknown

Neg

Pos

Other

Trace

Small

Moderate

Large

Unknown

+1

+2

+3

+4

Urine Test Type Urine Test Result Urine Test Units g/dL mcg/mg mcg/mmol mg/dL mcg/g mg/g mg/24 hours Other Unknown

24 hr. Urine protein

Microalbumin/creatinine

Urine creatinine

Urine albumin

Other Chemistry/Lipids/Urine/Toxoplasma/Hepatitis B and C PARID _ _ _ _ _ _ _ _ _ _ _ _

Toxoplasma, Hepatitis C and Hepatitis B Testing

Toxoplasma

Collection date

/ / mm/dd/yyyy

Toxoplasma IgG antibody result

Positive or Reactive Negative or Non-reactive Indeterminate

Hepatitis C

Collection date / / mm/dd/yyyy

Hepatitis C Test Type Hepatitis C Test Result

Antibody (Ab) Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Qualitative RNA test Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Quantitative RNA test (viral load )

Viral Load undetectable?

Yes

No

Viral load sign

< (less than) limit of detection or undetectable

> (greater than) or above upper limit of detection = (equal to) or detectable

Viral load result

(Only enter value if “Viral Load undetectable? = No”) Quantitative viral load units IU/mL Copies/mL Other__________ Unknown

Quantitative viral load upper limit _____________________________

Upper limit not documented Quantitative viral load lower limit _____________________________

Lower limit not documented

Hepatitis B

Collection date / / mm/dd/yyyy

Hepatitis B Test Type Hepatitis B Test Result

Surface antibody Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Surface antigen Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Core antibody Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Qualitative DNA test Positive/Reactive/Detected Negative/Non-reactive/Not detected Indeterminate

Quantitative DNA test (viral load):

Viral Load undetectable?

Yes

No

Viral load sign

< (less than) limit of detection or undetectable

> (greater than) or above upper limit of detection = (equal to) or detectable

Viral load (DNA) result

(Only enter value if “Viral Load undetectable? = No”) Viral load (DNA) units IU/mL Copies/mL Other____________ Unknown

Viral load (DNA) upper limit ___________________________

Upper limit not documented

Viral load (DNA) lower limit ___________________________

Lower limit not documented

Sexually Transmitted Infections Testing PARID _ _ _ _ _ _ _ _ _ _ _ _

SEXUALLY TRANSMITTED INFECTION SCREENING

Gonorrhea Details Collection date Source of Specimen Test Type Result mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

*DFA – Direct Fluorescent Amplification; ¶ DNA Probe – Nucleic Acid Probe (Direct Hybridization Probe Test); †EIA (ELISA) – Enzyme Linked Immunoassay; ‡NAAT – Nucleic Acid Amplification Test; ΩID – Indeterminate

Chlamydia Details Collection date Source of Specimen Test Type Result mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

ND

mm/dd/yyyy

Anorectal Cervical Vaginal Urethral

Urine Lymph node Pharyngeal Ocular

Not documented

Culture Gram Stain DFA* EIA† DNA probe¶

NAAT‡ Nucleic acid hybridization (probe) test

Not Documented

Pos

Neg

IDΩ

*DFA – Direct Fluorescent Amplification; ¶ DNA Probe – Nucleic Acid Probe (Direct Hybridization Probe Test); †EIA (ELISA) – Enzyme Linked Immunoassay; ‡NAAT – Nucleic Acid Amplification Test; ΩID - Indeterminate

Sexually Transmitted Infections Testing PARID _ _ _ _ _ _ _ _ _ _ _ _

Syphilis Details mm/dd/yyyy

Serum Cerebrospinal fluid (CSF) Tissue

Lesion exudate Lymph node

Not Documented

RPR*

PCR**

VDRL¶

TPHA®

FTA-ABS†

Dark Field

EIA††

CIA§

Positive/Reactive

Negative/non-reactive

IDΩ

TP-PA/MHA-TP‡ Treponemal Ab test, NOS ND

Titer 1: ___________________ mm/dd/yyyy

Serum Cerebrospinal fluid (CSF) Tissue

Lesion exudate Lymph node

Not Documented

RPR*

PCR**

VDRL¶

TPHA®

FTA-ABS†

Dark Field

EIA††

CIA§

Positive/Reactive

Negative/non-reactive

IDΩ

mm/dd/yyyy

Serum Cerebrospinal fluid (CSF) Tissue

Lesion exudate Lymph node

Not Documented

RPR*

PCR**

VDRL¶

TPHA®

FTA-ABS†

Dark Field

EIA††

CIA§

Positive/Reactive

Negative/non-reactive

IDΩ

mm/dd/yyyy

Serum Cerebrospinal fluid (CSF) Tissue

Lesion exudate Lymph node

Not Documented

RPR*

PCR**

VDRL¶

TPHA®

FTA-ABS†

Dark Field

EIA††

CIA§

Positive/Reactive

Negative/non-reactive

IDΩ

mm/dd/yyyy

Serum Cerebrospinal fluid (CSF) Tissue

Lesion exudate Lymph node

Not Documented

RPR*

PCR**

VDRL¶

TPHA®

FTA-ABS†

Dark Field

EIA††

CIA§

Positive/Reactive

Negative/non-reactive

IDΩ

*RPR-Rapid Plasma Reagen; ¶VDRL-Veneral Disease Research Lab; †FTA-ABS-Fluorescent Treponemal Antibody Absorption Test; ††EIA (ELISA)-Enzyme Linked Immunoassay; **PCR-Polymerase Chain Reaction;

®TPHA-Treponemal palladium particle agglutination assay; §CIA-Chemiluminescence Immunoassays; ‡TP-PA/MHA-TP-Treponemal palladium Particle Agglutination/ Microhemagglutination Assay; ΩID Indeterminate

Trichomonas Details mm/dd/yyyy

Anorectal Urethral Vaginal

Cervical Urine Not Documented

Culture NAAT† Microscopy Wet mount PCR‡

DNA probe* TMA§ EIA¶ ICG†

Nucleic acid hybridization (probe) test Not Doc

Pos Neg

IDΩ ND

mm/dd/yyyy

Anorectal Urethral Vaginal

Cervical Urine Not Documented

Culture NAAT† Microscopy Wet mount PCR‡

DNA probe* TMA§ EIA¶ ICG†

Nucleic acid hybridization (probe) test Not Doc

Pos Neg

IDΩ ND

mm/dd/yyyy

Anorectal Urethral Vaginal

Cervical Urine Not Documented

Culture NAAT† Microscopy Wet mount PCR‡

DNA probe* TMA§ EIA¶ ICG†

Nucleic acid hybridization (probe) test Not Doc

Pos Neg

IDΩ ND

mm/dd/yyyy

Anorectal Urethral Vaginal

Cervical Urine Not Documented

Culture NAAT† Microscopy Wet mount PCR‡

DNA probe* TMA§ EIA¶ ICG†

Nucleic acid hybridization (probe) test Not Doc

Pos Neg

IDΩ ND

†NAAT-Nucleic Acid Amplification Test; ‡PCR-Polymerase Chain Reaction; *DNA probe- Nucleic Acid Probe (Direct Hybridization Probe Test); §TMA-Transcription-mediated amplification;

¶EIA- EIA (ELISA)-Enzyme Linked Immunoassay; †ICG-Immunochromatography

Resistance and Tropism Testing PARID _ _ _ _ _ _ _ _ _ _ _ _

RESISTANCE DATA

Genotype/Virtual Phenotype Genotype or Virtual Phenotype performed

Yes

No/ND Go to Standard Phenotype

Lab report available in medical record for entry

Yes

No Go to Standard Phenotype

Type of test:

Genotype

Virtual Phenotype

Collection date / / mm/dd/yyyy

Specimen Adequate?

Yes No Go to Standard Phenotype

NRTI mutations detected:

Yes No/ND Go to NNRTI

NNRTI mutations detected:

Yes No/ND Go to PI

PI mutations detected:

Yes No/ND Go to Integrase

NRTI mutation position #:

NRTI mutation letter:

NNRTI mutation position #:

NNRTI mutation letter:

PI mutation position #:

PI mutation letter:

Integrase mutations detected:

Yes No/ND Go GP41

GP41 envelope mutations detected:

Yes No/ND Go to Standard Phenotype

Integrase mutation position #: Integrase mutation letter: GP41 mutation position #: GP41 mutation letter:

Standard Phenotype

Was a standard Phenotype performed (not a virtual phenotype)?

Yes No/Not Documented Go to Tropism Assay

Collection Date (mm/dd/yyyy)

Tropism Assay Tropism assay performed

Yes

No/NDEnd

Lab report available in medical record for entry

Yes

NoEnd

Collection date (mm/dd/yyyy)

Tropism Results: CCR5 (R5) Tropic CRCX4 (X4) Tropic Dual/mixed (D/M) Tropic

Specimen inadequate Unknown/Not documented

Resistance and Tropism Testing PARID _ _ _ _ _ _ _ _ _ _ _ _

RESISTANCE DATA

Genotype/Virtual Phenotype Genotype or Virtual Phenotype performed

Yes

No/ND Go to Standard Phenotype

Lab report available in medical record for entry

Yes

No Go to Standard Phenotype

Type of test:

Genotype

Virtual Phenotype

Collection date / / mm/dd/yyyy

Specimen Adequate?

Yes No Go to Standard Phenotype

NRTI mutations detected:

Yes No/ND Go to NNRTI

NNRTI mutations detected:

Yes No/ND Go to PI

PI mutations detected:

Yes No/ND Go to Integrase

NRTI mutation position #:

NRTI mutation letter:

NNRTI mutation position #:

NNRTI mutation letter:

PI mutation position #:

PI mutation letter:

Integrase mutations detected:

Yes No/ND Go GP41

GP41 envelope mutations detected:

Yes No/ND Go to Standard Phenotype

Integrase mutation position #: Integrase mutation letter: GP41 mutation position #: GP41 mutation letter:

Standard Phenotype

Was a standard Phenotype performed (not a virtual phenotype)?

Yes No/ND Go to Tropism Assay

Collection Date (mm/dd/yyyy)

Tropism Assay Tropism assay performed

Yes

No/NDEnd

Lab report available in medical record for entry

Yes

NoEnd

Collection date (mm/dd/yyyy)

Tropism Results: CCR5 (R5) Tropic CRCX4 (X4) Tropic Dual/mixed (D/M) Tropic

Specimen inadequate Unknown/Not documented

Remarks PARID _ _ _ _ _ _ _ _ _ _ _ _

Remarks (For Local Use Only – Do Not Enter into Discovere®)