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Documenting Results
The clinical value of HIV testing means that an HIV test result becomes part of the patient's medical chart, so that all providers caring for a patient have access to that information. Sites should consider documenting the following in the patient's chart:
- Whether an HIV test was declined
- Negative test results
- Confirmatory results (if applicable)
- Referral to follow-up care (if applicable)
- Viral loads and CD4 counts at the time of diagnosis (To help the ED track at what stage of illness they are detecting HIV in their patients.)
Key considerations for documenting test results include:
- Who has access to patient records and can input data? It is common practice that only laboratory or clinical staff may document test results in patients' charts.
- Does the ED use electronic medical records?
- Will results go into the patient's chart or into a separate, parallel documentation system for HIV testing? When the testing program operates as a separate and distinct program from the ED's medical services, it is likely that the test results will not be entered into the patient's medical record, but into a parallel tracking system.
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