Associate Name (print): ___________________________
Address: ________________________________________
Home phone:_______________________work ext:________
Date of Birth:____________
Hospital Associate
Blood Borne Pathogen Exposure (Needle Stick)
Standing Orders
Criteria:
This form is used by the Resource Nurse if the source patient is positive for HIV or unknown.
Exposed associate’s current medications: _____________________________________________
Exposed associate’s allergies: ______________________________________________________
Labs for Exposed Associate:
1.
HIV antibody
2.
Stat Blood Pregnancy test (if indicated for women of child bearing years)
Results:  Positive  Negative
3.
CMP
4.
Hepatitis B antibody (if associate’s Hepatitis B antibody status is unknown)
5.
Hepatitis C antibody
Treatment for Exposed Associate:
6.
Notify a Gwinnett Infectious Disease physician by paging them through Xtend (type “E-code”
in the search box and click on ID Physician)
7.
Provide associate counseling regarding medication benefits and side effects, as well as
needed precautions and instructions to follow-up with the ID physician prior to completing
the initial 6 doses of anti-viral medication.
8.
Obtain consent for antiviral medication:
Consent for the Exposed Associate:

I consent to treatment with antiviral medications and I’m aware of HIPAA regulations
and its availability on Gwinnettwork. I have been advised to follow-up with ID physician.
Date: ______Time: ______ Associate Signature: ______________________________

I decline treatment with antiviral medication, but have been advised to follow-up with ID
physician.
Date: ______Time: ______ Associate Signature: ______________________________
Consented Associates will receive:
Truvada (tenofovir 300mg and emtricitabine 200 mg) 1 tab po q day x 3 doses
and
Isentress (raltegravir) 400 mg po bid x 6 doses
________ ________ _________________________
Date
Time
Nurse Signature
Consented Associate to bring this order to GMC or GMC-D Pharmacy
Department ASAP (24 hrs per day, 7 days per week)
Dispensing Pharmacist: __________________, forward this form to Associate Pharmacy
and fax copy to Occupational Health, 770-682-2260.
*1-24315*
FORM 1-24315 REV. 02/2014
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