Chart Abstraction Form

Chart Abstraction Form 09-034S

Reviewer ______

Date ______

State Case Number ______

Identifying Characteristics w/TIMS Data

Patient’s gender  Male  Female

Patients case status:  Case  Reactivated case  Suspect  Atypical  Not TB

Initial Patient Interview

Does the patient speak English?  Yes  No  Unknown

If no, was as an interpreter provided during patient care?  Yes  No  Unknown

If no, why not: ______ Unknown

Was patient education and other communication provided in the patients’ preferred language?  Yes  No  Unknown

Where did the initial patient interview take place?  Private Physician  County TB program  Clinic, other than TB clinic  Hospital  Nursing home  Correctional facility  Other ______ Unknown

Professional title of provider that completed initial patient interview ______ unknown

Date of initial patient interview: ______ unknown

Was HIV status documented at initial patient interview?  Yes  No

If yes, results:  Negative  Positive  Pending results  Refused  Indeterminate  Unknown

Was this patient referred to the county clinic from a different provider?  Yes  No  Unknown

If yes, from where?  Private Physician  Clinic  Hospital  Other ______

If yes, was the patients HIV status documented within their previous paperwork?  Yes  No  Unknown

Who provided patient education at the initial meeting within the county’s program (Check all that applies)?  Doctor  Nurse  Outreach Worker  Other ______ Unknown

Self Reported HIV Status

Did the patient self-report his/her HIV status?  Yes  No  Unknown . If yes, date of self-report: ______ Unknown

If yes, date of previous HIV screening: ______ Unknown

If yes, site of previous HIV screening: ______ Unknown

If yes, method of previous HIV screening: ______ Unknown

If yes, reason for previous HIV screening: ______ Unknown

At which site did the patient provide his/her self-reported HIV status?  Private physician’s office  County TB program  Clinic, other than TB clinic  Hospital  Nursing home  Correctional facility  Other ______ Unknown HIV Screening

Was the patient educated about the risk of HIV/TB co-infection?  Yes  No  Unknown

Was an HIV test performed on the patient?  Yes  No  Unknown

If yes,

Date of documented HIV test: ______ unknown

Site of HIV test:  Private physician’s office  County TB program  Same county’s HIV program  Outside clinic  Hospital  Nursing home  Correctional facility  Other ______ Unknown

Was written consent provided to the patient?  Yes  No  Unknown

Professional title of provider that administered HIV test: ______ unknown

Type of HIV test used: ______ unknown

Date of laboratory report of HIV status results: ______

HIV Post-Test Counseling

Location of HIV post-test counseling  Private Physician  County TB program  Clinic, other than TB clinic  Hospital  Nursing home  Correctional facility  Other ______ Unknown

Date of HIV post-test counseling: ______ unknown

Professional title of provider that offered post-test counseling: ______ unknown

If patient is HIV positive

Was a second, confirmatory test given to the patient?  Yes  No  Unknown

If yes, date of administration: ______

IF HIV Test Not Offered

Reason for not offering HIV screening ______ unknown

Professional title of provider to document that the HIV screening not offered: ______ unknown

Date of documentation that the HIV screening not offered: ______ unknown

IF HIV Test Refused

Reason for refusal of HIV test: ______ unknown

Is there a specific location on the medical paperwork to document reason for refusal?  Yes  No  Unknown Was there an attempt made to re-educate the patient on the dangers of co- infection?  Yes  No  Unknown

Professional title of provider to document HIV test refusal:______ unknown

Date of documentation of HIV test: ______ unknown

IF HIV Test Referral

Site of patient referral for HIV screening: ______ unknown

Follow-up procedures: ______ unknown

Patient Risk Factors

Are patient risk factors documented?  Yes  No  Some  Other______

Professional title of provider who documented patient’s risk factors: ______

Date of documentation of patient’s behavioral risk factors: ______

Was the patient asked about their sexual behaviors?  Yes  No  Unknown

Was the patient asked about their marital status?  Yes  No  Unknown

Patient Supervision

Was the patient hospitalized for Tuberculosis?  Yes  No  Unknown

If yes, dates of hospitalization: ______

Was the patient institutionalized? (Correctional facility/nursing home)  Yes  No  Unknown

If yes, where: ______

Did the patient meet with his/her PCP during the course of treatment?  Yes  No  Unknown

If yes, date(s) of visit with PCP: ______

County TB Program

How often did the patient visit the county TB program?  Daily  Bi-weekly  Weekly  2-3 times per month  Monthly  Bi-monthly  Other: ______ Unknown

What services were provided by the county TB program (check all that apply)  Tuberculin skin testing  Medical evaluation  Professional medical consultation  Sputum induction  HIV counseling and testing  Radiographic studies  Treatment for TB infection  Treatment for latent TB infection  Directly observed therapy  Patient/provider/community education  Social services and referrals  Translation services  Unknown

Dates of visits to county TB program: ______

Case Supervision

How often was the case reviewed by a supervisor?  Weekly  Monthly  Other______ Unknown