Instructions For Case Reporting
PATIENT INFORMATION:
- Use the complete address (including city) for the patient. Morbidity is assigned to the county in which the patient currently resides.
- Complete the demographics; age, sex, and race.
SPECIMEN COLLECTION/DIAGNOSIS
Record the following:
- Date specimen collected: the date the specimen was collected by provider.
- Date of positive lab report and laboratory used: This is the date the laboratory report was received or called to your facility by laboratory used.
- Diagnosing Agency: Specify the name of agency that diagnosed the patient.
PMD - Private Medical Doctor (list the physicians name).
Public - any public health facility, including county health departments, family planning clinics, STD clinics.
IHS - Indian Health Service (specify which unit).
Other - all other reporting agencies: military, state institutions, Job Corps, student health agencies.
- Test type: Record what testing type was used. (NAAT, Probe, DNA)
- Patient diagnosis: List infecting agent(s) from below and specify site: pharyngeal, rectal, urethral, cervical, etc.
Gonorrhea
Gonococcal PID
Chlamydia
Chlamydial PID
- Fill out completely the provider's name, address, and phone number.
TREATMENT INFORMATION:
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List date treated, medication, dose, and duration of therapy.
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Interviewer Information: List name of the person who interviewed the patient and the date of the interview. List the name of the interviewing agency.
- Contact information: List name of each contact and the date of last exposure. Provide the date the contact was examined and/or treated. Provide location information in the "comments" section. List the disposition of the contact from the Disposition Codes.
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DISPOSITION CODES:
A. Preventive Treatment
F. Not Infected
B. Refused Preventive Treatment
G. Insufficient Information to Begin Investigation
C. Infected, Brought to Treatment
H. Unable to Locate
D. Infected, Not Treated
J. Located, Refused Examination
E. Previously Treated for this infection
K. Out of Jurisdiction
L. Other (List reasons for "other")
HIV INFORMATION: Indicate if patient was HIV counseled.
Send copy of case record via mail or FAX (800-616-7460) to the DPHHS STD Program, 1400 Broadway, Room C-211, Helena, MT 59620
STD Case Record Reporting Form
Page updated 2-22-08
