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The Confidential STD Morbidity Report form plays a crucial role in gathering data about sexually transmitted diseases within the community. Managed by the Houston Department of Health and Human Services, this form is essential for healthcare facilities and clinics to report cases of STDs. It collects demographic information about the patient, including their name, date of birth, social security number, and contact details. Additionally, the form requires the reporting facility to provide its information, ensuring a clear line of communication. Important health details are also captured, such as pregnancy status, marital status, and reasons for testing. The report is designed to document specific diseases, with checkboxes for various reportable conditions like syphilis, gonorrhea, and chlamydia. There's a section for signs and symptoms, laboratory results, and treatment history, which allows for comprehensive patient profiles. This structured approach not only aids in monitoring STD trends but also enhances public health responses and interventions.

Confidential Std Morbidity Report Example

CONFIDENTIAL STD MORBIDITY REPORT FORM

Houston Department of Health and Human Services

 

 

 

 

ATTN: Bureau of Epidemiology – STD Surveillance 4th floor

 

 

 

 

 

 

 

 

 

 

 

 

8000 North Stadium Drive

Houston, Texas 77054

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel: (832)393-5080 Fax: (832)393-5233

 

 

 

 

 

 

 

 

 

 

 

 

 

Reported by:

 

Facility/Clinic:

 

Phone Number:

 

 

 

 

Date:

 

 

 

 

 

 

 

PATIENT DEMOGRAPHIC DATA

 

 

 

 

 

 

 

 

 

Last Name

 

 

 

 

First Name, MI

 

 

 

 

 

 

 

 

 

 

 

 

DOB

 

 

 

 

Social Security #

 

 

 

 

 

 

Sex

 

 

 

Race

 

 

 

 

Hispanic

 

 

 

 

 

 

 

 

 

 

 

 

…Y

 

… N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

Home Phone

(

 

)

--

 

 

 

 

 

 

 

City, State Zipcode

 

 

 

 

Other Phone

(

 

)

--

 

 

 

 

 

 

 

Emergency Contact Name

 

 

 

 

Contact Phone

(

 

)

--

 

 

 

 

 

 

 

Marital Status

…Single

…Married …Divorced …Widowed …Unknown

 

 

 

 

 

 

 

 

 

Pregnancy Status

…N/A

…No … Yes (Expected delivery date___/___/___)

… Unknown (Last menstrual date___/___/___)

 

 

 

Reason for Test (STD related, prenatal;, immigration, etc):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISEASE DATA

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Reportable Disease(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

… Syphilis

 

… Gonorrhea

… Chlamydia

 

 

 

… Chancroid

 

 

 

 

List Signs and Symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Voluntary Disease(s)

… Genital Warts

… Non-specific Urethritis

 

… Pelvic Inflammatory Disease

 

 

 

 

…Genital Herpes

 

 

 

 

 

… Trichomoniasis

… Other non-specific Vaginitis

… Mucopurulent Cervicitis

 

… Other _________________

 

 

LABORATORY DATA

Date of Collection/Test

Diagnostic Test

Results

Laboratory

TREATMENT INFORMATION

Prior History of Treatment …Yes …No

… Unknown

Date of Previous Treatment _____/_____/_____

 

 

 

CURRENT TREATMENT INFORMATION:

Method of Prior Treatment_________________

 

 

 

 

 

 

 

 

 

 

Date (s) of Treatment

 

Method of Treatment / Dose

 

Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes/Comments/Patient History/Risk Factors:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Form Characteristics

Fact Name Fact Description
Purpose of the Form The Confidential STD Morbidity Report Form is designed to gather data related to the diagnosis, treatment, and demographics of patients with sexually transmitted diseases in order to aid public health surveillance and improve health service delivery.
Confidentiality All information reported on the form is confidential and protected by federal and state confidentiality laws, ensuring that personal patient information is not disclosed without proper consent.
State-Specific Governing Laws In Texas, the governing laws pertaining to the reporting of sexually transmitted diseases can be found in the Texas Health and Safety Code, specifically Title 1, Subtitle B, Chapter 81, which mandates the reporting of certain infectious diseases.
Submission Information The form should be submitted to the Bureau of Epidemiology – STD Surveillance at the Houston Department of Health and Human Services via fax or mail, with the contact information provided in the form details.

Guidelines on Utilizing Confidential Std Morbidity Report

After gathering the necessary information, you are ready to complete the Confidential STD Morbidity Report form. Make sure to provide accurate details in each section to ensure proper recording and follow-up. The steps below will guide you through the process of filling out the form.

  1. Enter the name of the facility or clinic where the patient is being reported in the "Facility/Clinic" section.
  2. Provide the phone number of the facility or clinic.
  3. Write the date of the report in the designated field.
  4. In the "Patient Demographic Data" section, input the patient's last name, first name, and middle initial.
  5. Fill in the patient's date of birth and social security number.
  6. Indicate the patient's sex and race.
  7. Mark whether the patient is Hispanic by selecting "Y" for yes or "N" for no.
  8. Complete the patient's address, including the city, state, and zip code.
  9. Provide the home phone number of the patient.
  10. If applicable, enter an alternate phone number for the patient.
  11. Fill in the name of the emergency contact and their phone number.
  12. Select the patient's marital status from the given options: Single, Married, Divorced, Widowed, or Unknown.
  13. Indicate the pregnancy status by selecting the appropriate option: N/A, No, Yes (with expected delivery date), or Unknown (with last menstrual date).
  14. State the reason for the test in the "Reason for Test" field, such as STD related, prenatal, or immigration.
  15. Check the reportable diseases that apply to the patient: Syphilis, Gonorrhea, Chlamydia, or Chancroid.
  16. List any signs and symptoms observed in the provided space.
  17. Check any voluntary diseases relevant to the patient: Genital Warts, Non-specific Urethritis, Pelvic Inflammatory Disease, Genital Herpes, Trichomoniasis, Other non-specific Vaginitis, Mucopurulent Cervicitis, or other (specify).
  18. In the "Laboratory Data" section, write the date of collection or test and provide the diagnostic test results along with the laboratory name.
  19. Indicate if there was a prior history of treatment and provide relevant information if applicable.
  20. Fill in the date of any previous treatment if known.
  21. In the "Current Treatment Information" section, state the method of prior treatment, including dates when applicable.
  22. Document the method of treatment, dosage, and name the provider.
  23. Utilize the notes/comments section to include any patient history or relevant risk factors.

What You Should Know About This Form

What is the purpose of the Confidential STD Morbidity Report form?

The Confidential STD Morbidity Report form is used to report and track sexually transmitted diseases (STDs) in Texas. It helps public health authorities gather crucial data regarding STD rates and trends, allowing for better disease control and prevention strategies. The information collected is vital for identifying outbreaks and ensuring proper treatment and follow-up for affected individuals.

Who should complete this form?

This form should be completed by healthcare providers, clinics, or facilities that diagnose or treat STDs. Anyone involved in the care of a patient with an STD can fill out the form, and it is important for accurate reporting to occur promptly. This ensures that the patient's treatment history is readily available for follow-up and public health monitoring.

What information is required on the form?

The form collects various types of information, including patient demographic details like name, date of birth, and contact information. It also asks about the patient's medical history, current treatment, and any related symptoms. Specific questions about STDs, such as whether the patient has been treated before, are essential for assessing the patient's condition and determining appropriate further steps.

Is the information on the form kept confidential?

Yes, the information provided on the Confidential STD Morbidity Report form is treated with the utmost confidentiality. Public health officials use the data solely for epidemic surveillance and health monitoring purposes. Any identifying information is protected by federal and state privacy laws to ensure that patients' rights are upheld.

How can I submit the form?

You can submit the Confidential STD Morbidity Report form via fax or by mailing it to the indicated address. For fax submissions, use the number provided on the form. It’s essential to ensure that all information is complete and accurate before sending the form for processing. Prompt submission will assist in timely action regarding public health measures.

What should I do if I have questions about completing the form?

If you have questions about how to fill out the Confidential STD Morbidity Report form, you can contact the Houston Department of Health and Human Services at the phone number listed on the form. They can provide guidance on any specific fields and clarify the reporting process. Reaching out can help ensure that the form is correctly completed and submitted without any issues.

Common mistakes

Filling out the Confidential STD Morbidity Report form can seem straightforward, but many individuals make common mistakes that can lead to issues down the line. First, one of the most frequent errors is providing incomplete patient demographic data. Missing a last name or date of birth can create confusion and hinder accurate tracking of cases.

Another mistake occurs when people neglect to include the correct Social Security number. This is crucial for identifying patients and ensuring confidentiality. Omitting it can slow down processing and potentially delay necessary follow-up.

When it comes to checking the reportable diseases, individuals sometimes fail to mark all applicable options. For example, if both Gonorrhea and Chlamydia are present, both should be indicated. Not doing so could lead to underreporting and skew public health data.

Additionally, some neglect to provide complete contact information. The form requests various phone numbers and an emergency contact, yet many leave these fields blank. Complete contact details are important for follow-ups and ensuring the patient receives appropriate care.

People also often forget to specify the reason for the test. Stating this is important, as it provides context for healthcare providers. A simple note about whether the test is for STD-related symptoms, prenatal care, or immigration can be very helpful.

Providing vague or incomplete notes about patient history and risk factors is another significant oversight. These details help healthcare providers understand the patient’s situation better. Comprehensive notes can guide treatment and outreach efforts efficiently.

Moreover, failing to document prior treatment accurately can lead to confusion. If previous treatments are recorded incorrectly or not at all, providers may prescribe the wrong medication or dosage, affecting the patient's recovery.

On occasion, people forget to include laboratory data, such as the date of collection and test results. This information is essential for tracking disease progress and for the effective management of patients. Leaving this section incomplete can lead to misinterpretations of a patient's health status.

In addition to these errors, individuals sometimes overlook checking voluntary diseases. Not checking them can lead to a lack of awareness about potential health risks and necessary screenings that may not be otherwise highlighted.

Lastly, one of the most common mistakes is submitting the form without a signature or date. This may seem small, but it is essential for finalizing the report. Incomplete submissions can delay processing and result in the need for resubmission, causing unnecessary interruptions in patient care.

Documents used along the form

The Confidential STD Morbidity Report form serves an essential role in the monitoring and response to sexually transmitted diseases. It is often accompanied by other forms and documents that help health departments collect, analyze, and track relevant health data effectively. Here are some commonly used forms that support the information contained in the morbidity report.

  • Patient Consent Form: This document ensures that patients give their permission for their health data to be shared for public health purposes. Consent is crucial, as it protects patient privacy while allowing necessary data collection and reporting.
  • Follow-Up Care Plan: After a diagnosis, a follow-up care plan outlines the recommended treatment and care for the patient. This document often includes information on follow-up appointments, therapy options, and any necessary referrals to specialists.
  • Health History Questionnaire: This form gathers detailed information about the patient’s medical history, including previous illnesses, treatments, and lifestyle habits. Understanding a patient’s background helps healthcare providers tailor their approach for better outcomes.
  • Referral Form: When a patient requires further evaluation or treatment from another specialist, a referral form is used to facilitate the transition. It provides important context about the patient’s condition and previous treatments, ensuring continuity of care.

Using these documents alongside the Confidential STD Morbidity Report form enhances the overall process of disease surveillance and patient care. Together, they create a comprehensive framework for managing public health effectively.

Similar forms

  • Case Report Form: Similar to the Confidential STD Morbidity Report, a Case Report Form documents patient details and clinical data for various diseases. Both forms capture significant demographic information and medical history to aid in public health surveillance.
  • Patient Intake Form: This form collects initial information from patients at healthcare facilities. Like the STD Morbidity Report, it includes patient demographic data, reason for visit, and contact details.
  • Health History Questionnaire: Used during patient visits, this document gathers information about a patient’s previous health conditions, treatments, and lifestyle. Both forms aim to create a comprehensive profile of the patient for effective diagnosis and treatment.
  • Infectious Disease Reporting Form: This document is filled out to report communicable diseases to health departments. It parallels the STD Morbidity Report by facilitating the tracking of disease prevalence and transmission within the community.
  • Emergency Contact Form: Like the STD Morbidity Report, this form provides crucial contact information. It ensures that healthcare providers can reach someone in case of an emergency.
  • Laboratory Test Request Form: This form requests laboratory tests and includes patient information and test specifics. It works in conjunction with morbidity reports by providing necessary test outcomes for accurate disease tracking.
  • Treatment Consent Form: Before treatment begins, this form obtains patient consent for medical procedures. It shares similarities with the STD Morbidity Report, as both documents ensure that treatment and reporting adhere to legal and ethical standards.

Dos and Don'ts

Here are six important things to consider when filling out the Confidential STD Morbidity Report form:

  • Do: Ensure all patient demographic information is complete and accurate.
  • Do: Use clear and legible handwriting if filling out the form by hand.
  • Do: Check all relevant reportable and voluntary diseases, marking each clearly.
  • Do: Include complete contact information for both the patient and the reporting facility.
  • Don't: Leave any required sections blank; this could delay processing.
  • Don't: Share the form with unauthorized individuals; confidentiality is crucial.

By following these guidelines, you help ensure the form is processed smoothly and maintains the necessary privacy standards.

Misconceptions

Misconception 1: The form is not confidential.

Many people believe the Confidential STD Morbidity Report form is not private. In fact, this form is designed to maintain patient confidentiality. The information submitted is only shared with authorized personnel for public health purposes.

Misconception 2: Only medical professionals can fill out the form.

Some think only doctors or nurses can complete this form. However, any healthcare provider involved in the care of the patient can fill it out. This includes clinic staff as long as they are trained on proper protocol and confidentiality practices.

Misconception 3: The form is only for reporting STDs.

While primarily used for STDs, the form can also be utilized for voluntary reporting of certain other conditions. This includes data on diseases that may not be strictly classified as STDs but are of public health interest.

Misconception 4: Submitting the form guarantees immediate medical intervention.

Some individuals may assume that filling out this form automatically triggers treatment or investigation of their case. However, the report is used for surveillance and data collection purposes, not for direct medical action.

Misconception 5: The information is used only for local health surveys.

A common belief is that the data collected is relevant only to local health agencies. In reality, the information plays a role in broader public health policies and research efforts at state and national levels. This ensures resources are allocated effectively to combat STDs.

Key takeaways

When using the Confidential Std Morbidity Report form, there are several essential points to keep in mind:

  • Confidentiality is crucial. Always ensure patient information is handled with the highest level of confidentiality. Protecting patient privacy builds trust and encourages individuals to seek necessary treatment.
  • Accurate data collection is vital. Fill out every section of the form carefully. This includes personal demographics, disease data, and treatment information. Accurate data helps in effective disease tracking and managing public health.
  • Timeliness matters. Submit the report as soon as possible after diagnosis. Prompt reporting leads to quicker public health responses, which can help prevent the spread of STDs in the community.
  • Know the resources available. Familiarize yourself with the contact information provided on the form, including the dedicated phone line and fax number. This ensures you have support when you need to ask questions or clarify information.

Following these takeaways will enhance the effectiveness of the reporting process and contribute to better public health outcomes.