<p>Chart Abstraction Form 09-034S</p><p>Reviewer ______</p><p>Date ______</p><p>State Case Number ______</p><p>Identifying Characteristics w/TIMS Data</p><p>Patient’s gender  Male  Female </p><p>Patients case status:  Case  Reactivated case  Suspect  Atypical  Not TB </p><p>Initial Patient Interview</p><p>Does the patient speak English?  Yes  No  Unknown</p><p>If no, was as an interpreter provided during patient care?  Yes  No  Unknown</p><p>If no, why not: ______ Unknown</p><p>Was patient education and other communication provided in the patients’ preferred language?  Yes  No  Unknown</p><p>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</p><p>Professional title of provider that completed initial patient interview ______ unknown</p><p>Date of initial patient interview: ______ unknown</p><p>Was HIV status documented at initial patient interview?  Yes  No </p><p>If yes, results:  Negative  Positive  Pending results  Refused  Indeterminate  Unknown</p><p>Was this patient referred to the county clinic from a different provider?  Yes  No  Unknown</p><p>If yes, from where?  Private Physician  Clinic  Hospital  Other ______</p><p>If yes, was the patients HIV status documented within their previous paperwork?  Yes  No  Unknown </p><p>Who provided patient education at the initial meeting within the county’s program (Check all that applies)?  Doctor  Nurse  Outreach Worker  Other ______ Unknown</p><p>Self Reported HIV Status</p><p>Did the patient self-report his/her HIV status?  Yes  No  Unknown . If yes, date of self-report: ______ Unknown</p><p>If yes, date of previous HIV screening: ______ Unknown</p><p>If yes, site of previous HIV screening: ______ Unknown</p><p>If yes, method of previous HIV screening: ______ Unknown </p><p>If yes, reason for previous HIV screening: ______ Unknown </p><p>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</p><p>Was the patient educated about the risk of HIV/TB co-infection?  Yes  No  Unknown</p><p>Was an HIV test performed on the patient?  Yes  No  Unknown</p><p>If yes,</p><p>Date of documented HIV test: ______ unknown</p><p>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</p><p>Was written consent provided to the patient?  Yes  No  Unknown</p><p>Professional title of provider that administered HIV test: ______ unknown</p><p>Type of HIV test used: ______ unknown</p><p>Date of laboratory report of HIV status results: ______</p><p>HIV Post-Test Counseling</p><p>Location of HIV post-test counseling  Private Physician  County TB program  Clinic, other than TB clinic  Hospital  Nursing home  Correctional facility  Other ______ Unknown</p><p>Date of HIV post-test counseling: ______ unknown</p><p>Professional title of provider that offered post-test counseling: ______ unknown</p><p>If patient is HIV positive</p><p>Was a second, confirmatory test given to the patient?  Yes  No  Unknown</p><p>If yes, date of administration: ______</p><p>IF HIV Test Not Offered </p><p>Reason for not offering HIV screening ______ unknown</p><p>Professional title of provider to document that the HIV screening not offered: ______ unknown</p><p>Date of documentation that the HIV screening not offered: ______ unknown</p><p>IF HIV Test Refused</p><p>Reason for refusal of HIV test: ______ unknown</p><p>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</p><p>Professional title of provider to document HIV test refusal:______ unknown</p><p>Date of documentation of HIV test: ______ unknown</p><p>IF HIV Test Referral </p><p>Site of patient referral for HIV screening: ______ unknown</p><p>Follow-up procedures: ______ unknown</p><p>Patient Risk Factors </p><p>Are patient risk factors documented?  Yes  No  Some  Other______</p><p>Professional title of provider who documented patient’s risk factors: ______</p><p>Date of documentation of patient’s behavioral risk factors: ______</p><p>Was the patient asked about their sexual behaviors?  Yes  No  Unknown </p><p>Was the patient asked about their marital status?  Yes  No  Unknown</p><p>Patient Supervision</p><p>Was the patient hospitalized for Tuberculosis?  Yes  No  Unknown</p><p>If yes, dates of hospitalization: ______</p><p>Was the patient institutionalized? (Correctional facility/nursing home)  Yes  No  Unknown</p><p>If yes, where: ______</p><p>Did the patient meet with his/her PCP during the course of treatment?  Yes  No  Unknown</p><p>If yes, date(s) of visit with PCP: ______</p><p>County TB Program </p><p>How often did the patient visit the county TB program?  Daily  Bi-weekly  Weekly  2-3 times per month  Monthly  Bi-monthly  Other: ______ Unknown</p><p>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</p><p>Dates of visits to county TB program: ______</p><p>Case Supervision</p><p>How often was the case reviewed by a supervisor?  Weekly  Monthly  Other______ Unknown</p>