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    This document contains a checklist for assessing and documenting a patient's eligibility for HIV post-exposure prophylaxis (PEP) following a potential exposure incident. The checklist collects information on the exposure incident, the exposed individual's testing and medical history, and characteristics of the exposure source. It is also used to document PEP management decisions including whether PEP was recommended, consent obtained, medications prescribed, and follow-up plans.

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    Checklist NPEP

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    This document contains a checklist for assessing and documenting a patient's eligibility for HIV post-exposure prophylaxis (PEP) following a potential exposure incident. The checklist collects information on the exposure incident, the exposed individual's testing and medical history, and characteristics of the exposure source. It is also used to document PEP management decisions including whether PEP was recommended, consent obtained, medications prescribed, and follow-up plans.

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    52 views1 page

    NPEP Checklist

    Uploaded by

    dedekfriday
    This document contains a checklist for assessing and documenting a patient's eligibility for HIV post-exposure prophylaxis (PEP) following a potential exposure incident. The checklist collects information on the exposure incident, the exposed individual's testing and medical history, and characteristics of the exposure source. It is also used to document PEP management decisions including whether PEP was recommended, consent obtained, medications prescribed, and follow-up plans.

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    HIV POST-EXPOSURE PROPHYLAXIS CHECKLIST

    For further information see Post-exposure prophylaxis after non-occupational and occupational exposure to HIV: Australian National guidelines (Second
    edition) available at www.pep.guidelines.org.au. This checklist is intended as an aid only and local expert advice should be sought before use.
    FIRST TWO LETTERS OF SURNAME UNIQUE ID
    FIRST TWO LETTERS OF FIRST NAME DOB POSTCODE
    Sex assigned at birth ❍ Male ❍ Female Gender Identity ❍ Male ❍ Female ❍ Non-binary

    SEXUAL ASSAULT? ❍ Yes ❍ No Assailant known? ❍ Yes ❍ No

    TESTING AND MEDICAL HISTORY


    Previous Baseline Following Current Exposure
    Condition Result Date Result Date Other results
    ❍ HIV ❍ +ve ❍ -ve ❍ +ve ❍ -ve ❍ Biochemistry/liver function tests
    ❍ Hepatitis C ❍ +ve ❍ -ve ❍ +ve ❍ -ve ❍ Pregnancy ❍ +ve ❍ -ve
    ❍ Syphilis ❍ +ve ❍ -ve ❍ +ve ❍ -ve Current and past medical history, e.g. renal disease:
    ❍ Other STIs ❍ +ve ❍ -ve ❍ +ve ❍ -ve
    ❍ HBsAg ❍ +ve ❍ -ve ❍ +ve ❍ -ve All medications and drug allergies:
    ❍ Anti-HBs ❍ +ve ❍ -ve ❍ +ve ❍ -ve
    ❍ Anti-HBc ❍ +ve ❍ -ve ❍ +ve ❍ -ve Psychiatric history:
    ❍ Hepatitis A IgG ❍ +ve ❍ -ve Drug and alcohol history:

    CHARACTERISTICS OF EXPOSURE
    Date of exposure / / Time of exposure am/pm Place of exposure:
    Sexual contact Sharps exposure
    ❍ Receptive anal sex: ❍ ejaculation ❍ withdrawal ❍ Occupational ❍ Non-occupational
    ❍ Insertive anal sex: ❍ circumcised ❍ uncircumcised ❍ Reuse of injecting equipment ❍ Other needle-stick injury

    ❍ Receptive vaginal sex ❍ Hollow bore needle ❍ Solid bore needle ❍ Solid sharp
    ❍ Insertive vaginal sex: ❍ circumcised ❍ uncircumcised Other exposure
    ❍ Receptive oral sex ❍ Insertive oral sex ❍ Mucous membrane: ❍ occupational ❍ non-occupational
    Other risks ❍ Blood splash:
    Condoms used? ❍ Yes ❍ No ❍ superficial ❍ non-intact skin ❍ mucous membrane
    Condom: ❍ broke ❍ slipped ❍ removed by source Under the influence of alcohol or drugs? ❍ Yes ❍ No

    RISK CHARACTERISTICS OF SOURCE


    Sex ❍ Male ❍ Female ❍ Non-binary
    HIV positive Antiretroviral use Source HIV risk Partner +ve -ve Unknown
    ❍ known ❍ no ARV ❍ MSM ❍ regular HBV ❍ ❍ ❍
    ❍ suspected ❍ unknown ❍ Injecting drug use ❍ casual HCV ❍ ❍ ❍
    ❍ unknown ❍ past ARV ❍ High prevalence ❍ other STIs ❍ ❍ ❍
    Last viral load: Date: ❍ current ARV country Which STIs, if any:

    TRIAGE AND PEP ASSESSMENT


    Date / / Time am/pm Location
    Management
    Post exposure prophylaxis for HIV recommended? ❍ Yes ❍ No Hepatitis B immunoglobulin / /
    Regimen commenced? ❍ Yes ❍ No Hepatitis B vaccine / /
    Has patient taken PEP in the last 12 months? ❍ Yes ❍ No Was patient referred to counselling? ❍ Yes ❍ No
    Did patient consent to receive PEP? ❍ Yes ❍ No Reason not referred?
    Date PEP was received / / Time: am/pm Was PrEP discussed? ❍ Yes ❍ No
    Follow-up date / / & Location ❍ GP ❍ SHC ❍ Other Was PrEP recommended? ❍ Yes ❍ No

    Drug prescribed Dose Frequency I confirm that the above patient has had an exposure incident that may
    be a risk for HIV transmission. The result of the assessment for eligibility
    for HIV PEP is documented and drugs prescribed.
    Prescriber’s signature
    Prescriber’s name
    Provider number
    Contact details
    Contraception given? ❍ Yes ❍ No
    Telephone

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