• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (737) 255-4300

    Email the HIV/STD Program

    Email data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

POPS Chapter 2 - HIV-STI-HCV Testing and Linkage Documentation


This section provides guidelines for appropriate documentation of testing and linkage in client records related to HIV, sexually transmitted infections (STI), hepatitis C virus (HCV), and release of information relating to HIV antibody testing.

 

2.1 Documentation in Client Record

As a minimum standard, a client record will be initiated on each person seeking services at a HIV, STI, and HCV testing and linkage site. Contractors funded to provide focused testing and linkage must develop systems to document information consistent with confidentiality laws.

 

2.1.1 Minimum Requirements for HIV/STI/HCV Testing and Linkage Documentation

Records will include all issues discussed in the testing session relevant to HIV, STI, and HCV risk and prevention. Each client’s record must include:

  1. Client’s race, sex, ethnicity, and date of birth;

  2. Signed consent form (if testing anonymously, consent is appropriately signed);

  3. Copy of HIV and other test results;

  4. Brief HIV exposure risk assessment;

  5. Documentation that basic information about HIV, STI, and HCV infection and testing was provided;

  6. Documentation that the client was screened for PrEP and nPEP, and Acute HIV Infection (when indicated); and

  7. Documentation of referrals, as appropriate.

In addition to the items above, persons diagnosed with HIV and/or an STI must have the following information included in their chart:

  1. Documentation of referral, follow-up, and confirmation to HIV/STI-related medical care;

  2. Documentation that public health follow-up has been coordinated with the local or regional health department (for persons testing positive for HIV and/or syphilis); and

  3. Documentation that the person’s name has been reported to the local or regional health department, as required by law.

If a client refuses to provide any required information, document client refusal in the record.

 

2.1.2 Consent to Testing for HIV

In accordance with Vernon's Texas Code Annotated, HSC §§81.105 Informed Consent and Health and Safety Code HSC §§81.106 General Consent, a test designed to identify HIV transmission may not be performed without first obtaining the informed consent of the person being tested.

Consent need not be written if there is documentation in the client’s chart that the test has been explained to the client and verbal consent has been obtained. A person who has signed a general consent form for the performance of medical tests or procedures is not required to sign a specific consent form relating to HIV testing during the time in which the general consent form is in effect.

The result of a test for HIV performed under the authorization of a general consent may be used only for diagnostic or other purposes directly related to medical treatment of the client. Some institutions may have stricter policies concerning consent for HIV testing than that stated in statutes.

Violation: An individual or entity that tests without consent has committed a Class A misdemeanor.

 

2.1.3 Minor Consent

In accordance with Texas Family Code §32.003 Consent to Treatment by Child, a minor may consent to the diagnosis and treatment of STI that are required by law to be reported, including HIV, gonorrhea, chlamydia, chancroid, and syphilis regardless of the minor’s age and without the consent of the minor’s parent or guardian.

 

2.2 Anonymous and Confidential Testing for HIV

The terms anonymous and confidential have specific meanings regarding HIV testing.

Anonymous HIV testing - Anonymous testing refers to the practice of selecting a pseudonym consisting of a first name with a series of numbers (e.g., John 123, Jane 234) to assign to the documentation. Anonymous test results do not go into a client’s medical record. The client should be made aware that unless the client returns for results the testing center may not be able to locate the person to provide the test results.

Confidential HIV testing - Confidential testing links valid name and locating information to test documentation and the test results are placed in the client’s medical record. The client will be informed that the location information in their record will be used to contact a client who does not return for results.

Clients may choose to be tested either confidentially or anonymously. All test results are maintained in a confidential manner regardless of the method selected by the client.

 

2.2.1 Documentation for Anonymous HIV Testing

An anonymous HIV test requires use of a pseudonym consisting of a first name with a series of numbers (e.g., John 123, Jane 234) on documentation and retains no identifying or locating information beyond the demographic information required for the collection of epidemiological information. Some clients may request a phone call or text when their test results are received by the agency. In this instance, locating information may be retained by the agency where the client sought the HIV test.

The pseudonym should not be placed in the client’s medical record. Clients who test anonymously will sign the consent form using the agreed-on pseudonym.

 

2.3 Reporting

All positive HIV, STI, and preliminary positive results from a rapid HIV test will be reported according to standards and procedures outlined in Chapter 8, HIV/STI Surveillance.

For more information on disease reporting see DSHS website: dshs.texas.gov/hivstd/reporting/ 

 

2.3.1 Release of Information

All information and records relating to reportable diseases are to be kept confidential. Contractors must have a process in place to ensure the identity of the person returning for test results. Test results or other information that could identify a client may not be released or made public. HIV and STI testing information may be released only under the following circumstances:

  1. To the local health authority, regional public health department, or to the Department of State Health Services (DSHS) in accordance with regulations for disease reporting;

  2. As statistical information, but only if persons cannot be identified in the information;

  3. Under strict and legally defined conditions when a possible exposure has occurred, as determined by legal counsel on a case-by-case basis;

  4. To the client directly; directly – if your agency is providing written test results they should be provided on agency letterhead or similar form and clearly state:

    • Name of the agency and the date the test was conducted

    • Test result (positive or negative)

    • Explanation of the result relative to the window period and/or date for retesting

  5. Written results should not be provided when conducting anonymous HIV testing; and

  6. To another party with the client’s written consent.

If the client wants a copy of their test results or other confidential information to be released to a third party, an Authorization to Release Confidential Information Form should be completed and signed by the client. The form will specify to whom the information is being released, the purpose of the release and the specific information to be released.

 

2.4 Transmission of Medical Information via Electronic Machines

Facsimile (FAX) transmission of confidential information must only be done when other methods of sending information are unavailable or would delay the timely provision of services. To ensure that a breach of confidentiality does not occur when transmitting medical information via fax machines, faxing confidential information should fall under the following guidelines:

  1. Confidential information sent using a fax must be faxed under a cover sheet;

  2. The cover sheet must not contain the words HIV, AIDS or STI anywhere on it; and

  3. Information to be faxed must:

    • Be De-identified (client's name and all other identifying information removed);

    • Have identifying information sent in a separate fax transmission only after the sender has confirmed receipt of the first fax with the receiver; or

    • Have all HIV/STI-related information removed or converted to a code.

  4. Anyone sending a fax must confirm that the information faxed was received by the intended recipient;

  5. Fax machines used to send or receive confidential information must be located in a secure area;

  6. Programs are encouraged to use separate fax machines instead of multifunctional machines which include faxing capabilities;

  7. Call the receiver of the fax to ensure that the fax is located in a secure area and make them aware that a confidential fax is being sent over;

  8. Remove any HIV identifiers from the documents being sent over including position title, business name or department title; and

  9. Follow up with the receiver once the fax has been submitted to ensure receipt.

The below information can be referenced in Chapter 1.3 Confidentiality.

Violation: In accordance with Health and Safety Code HSC §81.103 Confidentiality; Criminal Penalty, breach of confidentiality is a Class A misdemeanor and is punishable by up to one year in jail and fines of up to $5,000. Violation of confidentiality is also a civil offense that may result in liability for damages plus fines.

Additional DSHS security and confidentiality guidance can be reviewed at dshs.texas.gov/hivstd/policy/procedures/2016-01.shtm

 

2.5 Retention of Client Records

The agency will have a system in place that complies with current confidentiality laws to protect client or patient records and documents maintained in connection with HIV/STI prevention activities.

Retention Guidelines are as follows:

Positive syphilis test results - All STI records containing positive syphilis test results (including congenital syphilis) must be maintained until 7 years past the death of the patient if known, or 18 years from the last date of service. STI medical records must be kept 7 years past the last date of service or until the patient’s 21st birthday, whichever comes later.

STI intervention records - All STI intervention records (including investigations, interviews, and disease intervention case management notes) must be kept 3 years past the last date of service or until the patient’s 21st birthday, whichever comes later.

Adults who are HIV-positive - Prevention counseling notes, risk reduction plans, and case management records compiled on HIV-positive adult clients must be maintained for 7 years past the last date of service or patient’s death, if known.

Children who are HIV-positive - For children diagnosed with HIV, the records must be kept for 3 years after the 21st birthday, even in death, or 7 years, whichever comes later.

HIV and AIDS disease intervention records - HIV and AIDS disease intervention records (including investigations, interviews, and disease intervention case management notes) must be kept 3 years past the last date of service or until the patient’s 21st birthday, whichever comes later.

Anonymous HIV-positive test results - HIV-positive anonymous test results (including serology, counseling notes, risk reduction plan, and prevention case management notes) must be maintained 1 year passed the test date or last date of service, whichever comes later.

Anonymous HIV-negative test results - HIV-negative anonymous test results (including serology, counseling notes, and risk reduction plan) are retained for 90 days after test date, or when the results are given to the client, whichever comes first.

Confidential HIV-positive test results - HIV-positive confidential test results (including serology and medical records) must be maintained for 7 years after the patient’s death, if known, or 18 years from the last date of service.

Confidential HIV-negative test results - HIV-negative confidential test results (including serology, counseling notes, and risk reduction plan) are maintained 7 years past the last date of service or until the patient’s 21st birthday, whichever comes later.

 

2.6 Record Destruction

Confidentiality must be maintained when destroying HIV/STI records. State records may be destroyed when:

  1. Its records series is listed on the records retention schedule for your area;

  2. It meets the retention period for that records series; and

  3. The record is not involved in a pending or ongoing lawsuit, claim, negotiation, administrative review, open records request or audit.

Agencies must record the destruction of record copies of state records on a Destruction/Disposition of Records form and have an administrator sign the log. Information regarding procedures for destruction of all state records, in whatever medium created, can be referenced from the Records Management Office.

Confidential records to be destroyed must be shredded. The destruction of record copies of state records must be documented on the Destruction/Disposition Form and with the signature of the program administrator or records coordinator. This shredding may take place in your program area; if your agency is located in Austin, you may have the staff from Executive and Staff Operations pick up your records for bulk shredding. Staff in the hospitals and regions may have a local vendor shred their records after sending the Disposition Logs.

The forms that may be needed to prepare records for destruction are: Destruction/Disposition of Records form (Word file*), Records Destruction Disclosure Form (restricted to DSHS employees in Austin), and if the records are not on an approved DSHS retention schedule: RMD 102-Request for Authority to Dispose of State Records (restricted to DSHS employees). DSHS employees may download the Records Destruction Disclosure Form and RMD 102-Request for Authority to Dispose of State Records at the Forms and Literature Order Entry and Inquiry System. For further information, contact the Records Management Office at (512)776-7635.

 

2.7 List of Helpful Websites and Websites Referenced in Chapter 2

Information on disease reporting can be found at the following DSHS website: dshs.texas.gov/hivstd/reporting/ 

Information on reporting rapid HIV test results can be found on the Technical Assistance page at the following DSHS website: dshs.texas.gov/hivstd/fieldops/techassist.shtm

Information regarding procedures for destruction of all state records can be found on the Records Management Office page at the following DSHS website: dshs.texas.gov/retention/

Records Destruction Disclosure Form and RMD 102-Request for Authority to Dispose of State Records can be found at the Forms and Literature Order Entry and Inquiry System page at the following DSHS website: hhsc.mypinnaclecart.com

Centers for Disease Control and Prevention: cdc.gov

Texas Constitution and Statutes: statutes.legis.state.tx.us

Health and Safety Code: statutes.legis.state.tx.us/?link=HS

Texas Family Code: statutes.legis.state.tx.us/?link=FA

Vernon's Texas Code Annotated (HSC §§81.105): statutes.legis.state.tx.us/Docs/HS/htm/HS.81.htm#81.105


 

 

Subchapters

2.1 Documentation in Client Record

2.2 Anonymous and Confidential Testing for HIV

2.3 Reporting

2.4 Transmission of Medical Information via Electronic Machines

2.5 Retention of Client Records

2.6 Record Destruction

2.7 List of Helpful Websites and Websites Referenced in Chapter 2

Last updated May 7, 2020