Free Answering Brief in Opposition - District Court of Delaware - Delaware

- · Case 1 :04-cv-01334-KAJ Document 34-2 Filed 03/28/2006 Page 1 of 2
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A » . I · - Case 1 :04-cv-01 I Document 34-2 Filed 03/23/2006 Page 2 of 2
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_ ` ‘`/` ` M MEDICAL
CHECKIAIST FOR HCV TREATMENT
his form must be completed by a Facility Provider for each Hepatitis C positive identified patient, after
Jmpleting Work-Up for Ab-normal LFTs form, regardless of treatment status.
TEP ONE: A ?/ 0
a) Hep C Antibody (Qtest 86803) Date -
b) Hep C continuation (Qtest# 87522) D-ate Tr ll/V)
c) Most current A T (must have 3 over past : ° Q; i
Date & Level ate & Level _ Date & Level A F {YL I Ii/LU
d) HIV status ositive / egativ~· (circ. ne) Date ( ‘ p/ 0/if 7 ,
e) Hep. B. Surface Antigen Positive egati - circle one) Date ,¤ 4
f) HCV Genotype Results Date I W
ITEP TWO: r _
1) Completed exclusion/inclusion checklist dc meets all inclusions:
Affirmative Negative (circle one) Date
2) No exclusions found:
Affirmative Negative (circle one) Date
‘"”` » P THREE
. *If answer to 1) is Affirmative and 2) is Mfirmative then:
A.) Completely review with patient and obtain consent/refusal for liver biopsy
and treatment on FCM HCV Consent for Treatment form.
B.) In addition, if consented for Treatment — submit this form for approval,
along with Consult request for liver Biopsy to FCM Delaware Office for Medical Director to complete.
. C.) Please give the inmate, along with verbal instruction, a copy of the Inmate
HCV information sheet (please date, sign, and file with this form in the medical record.
STEP FOUR
Regardless of whether the inmate is eligible for treatment or consents! refuses Hepatitis C treatment they
must be offered the following (to be documented on the FCM Inmate TB/Immunization form):
A.) Hepatitis A vaccine (no serology indicated)
B.) Hepatitis B vaccine series if HBsAB (-) and HBSAG (-)
C.) Refusal of vaccine needs to be noted on the FCM rehisal of Treatment form.
TO BE COMPLETED BY THE FCM STATE MEDICAL DIRECTOR:
Approval for Hep C Treatment to be initiated Date
Approval! Denial for Liver Biopsy . Date
Denial of Hep. C. Tx — Please indicate why
Date
*If answer t » 1) is Negative OR 2) is Negative then the patient ineligible for Treatment. The
· p inmate mus-t be educated as to reasons why they are ineligible, then this documentation and copy
' ef Imna-te HCVInforn1atien sheet must he sign-ed, dated and filed with this form in the chart.
Physician Signature li AL .*’; ‘ - Date I I gg I -i_:i V -
Admin—20U7 First Correctional Medical Y ·1'Qp1'ie1;a.1jy lnfonnation November 2002