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Forms - HIV Early Intervention Services (EIS)
Resources
  • Annual Medical Flow Sheet - This form allows for a quick review of patient past care and current status for EIS staff and specialist, with the purpose of eliminating time intense chart search for pertinent HIV care information, as well as documentation of HIV standard of care requirements. It is to be completed and updated by clinic staff prior to HIV specialist visits and kept in a prominent place in the medical chart.
  • Case Conference - This form is to be completed by the nurse case manager during the case conference held at each HIV specialty clinic, and placed in both the medical chart and case management chart.
  • Client Services List
  • Consent for Exchange of Confidential Information - This is to be completed by patient coordinator and patient annually or as needed for additions and changes. It must be on file for any exchange of medical information, and a copy must be kept in the medical chart and case management chart.
  • Consumer Medications List - This form was developed by a physician to be used by consumers to report all the medications they are taking. It is to be completed annually, or as needed, and brought to the quarterly clinic for the patient coordinator and primary care provider to review.
  • Consumer Services Review Checklist - This is to be used by patient coordinators initially, quarterly with all new patients, and as needed with established patients to make them aware of all the services available to them through the EIS program. A signed form is kept in the medical chart, and a copy is given to the patient.
  • CQI Peer Review Form - This form is printed and prepared by the patient coordinator, and is a required quality improvement activity.  One form is given to the HIV specialist during the clinic for the patient seen that day. The form is completed by the HIV specialist, and any recommendation for care made by the specialist should be noted in the chart. The form is not placed in the chart, but is collected and given to the program medical director for CQI review.
  • Health Education Topics - This is used by nurse case manager when providing required health education and risk reduction education as a tool to determine educational needs and document sessions. A copy is kept in the medical chart and case management chart.
  • Medical Screenings/Exams/Immunizations Client Form
  • Oral Assessment - This is to be used by the patient coordinator to assess oral health needs and develop referral to oral health care. It is a form kept in the medical chart, and the referral and follow-up are documented on the Patient Coordination Flow Sheet.
  • Patient Coordination Flow Sheet - This form allows for quick review and documentation of required EIS clinic activities performed by patient coordinator and other non-physician staff. It is to be completed during quarterly HIV clinics and kept in a prominent place in the medical chart.
  • Patient Medical Collection Form - This optional form can be used to collect data from the medical chart to be entered into the required ARIES data system.
  • PPD Screening Form - This form is for use in evaluating a PPD test site, and has a ruler and body image for clinical and charting use.
  • Primary Care Fee Schedule - This is used by patient coordinators on an annual basis to inform patients of the potential share of cost as required by HRSA. A signed copy is kept in the medical chart, and a copy is given to the patient.
  • Resource Evaluation - This form is used by the patient coordinator / case manager to review patient financial information and needed services, and used to determine payor of last resort. A copy is kept in the medical chart and case management chart.
 
For More Information
If you have any questions, please contact program coordinator Karla Burnworth at (530) 283-6357.

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