10.7 Appendix G - Examples of Documentation Procedures

10.7.1 Example - Massachusetts

Documentation Requirements

• The DIS will document all Internet activity.
• DIS must document all work with the date, time and description of each interaction on the Internet PN Log Sheet.
• All e-mail documentation should be kept in a case file.
• Internet PN must be entered and kept up-to-date in STD*MIS (see below).

Entering Internet Screen names into STD*MIS

This section of the policy seeks to address sexual contacts of infected individuals who are known to the infected patient by their screen names or e-mail addresses only.  This flexible approach is based on how much information is available about a partner and serves as a systematic way to maintain accurate records of not just names, addresses and phone numbers, but also screen names.  In this way, we can perform searches for individuals by their screen names and/or e-mail addresses when no other information is available.

• Individuals who are only known by their screen name are entered into STD*MIS as: Internet, screen name (For example, Internet, Sexyperson.)  Both the first and last names should be updated when more information becomes available.
• Screen names are entered into the Also Known As (AKA) section.  AKAs should never be changed or deleted.  New screen names must be added as needed.  (It is important to note that individuals can be searched for in STD*MIS by their AKA only- no other information about first or last names is needed to perform a search.)  If the individual is not currently in the STD*MIS system, we can add them and open a new Field Record.
• Screen names pertain to specific Internet sites.  These sites (Manhunt, AIM, Yahoo, etc.) must be noted in the Notes section of the Field Record.  Individuals may change their screen names frequently, so it is essential that the date of the last known use of the screen name be noted in the Notes section.  (For example: MH “Sexyperson” 4/19/06, Yahoo “SexyP” 4/19/05, AIM “SexyPER” 4/19/04.)
• The way we currently manage missing locating information remains the same.  For example, if we know a client’s first name and address, this individual is entered into the system as “John UNK.”  Now, with this new system for entering names into STD*MIS, sexual contacts will be entered into the system as “Internet, screen name,” or, if we know the client’s first name, “John Internet.”
• Case dispositions should be entered into STD*MIS with the following codes (STD*MIS does not allow numbers to be entered after letter codes; this can be noted in the case file):

Code	Description
A *	Preventative treatment (not infected - confirmation of examination and/or treatment)
C *	Infected, brought to treatment (infected - confirmation of examination and/or treatment)
L1 **	Patient states examination and/or treatment (not infected - no provider confirmation)
L2 **	Patient states examination and/or treatment (infected - no provider confirmation)
J **	Informed of disease exposure - no further contact with MPDH (located, received specific STD exposure info, no further contact with MDPH)
H1	E-mails read but never responded (located but refused to respond, did not receive specific STD disease information)
H	E-mail(s) not read (unable to locate)

* Infers direct contact with DIS
** Infers e-mail or phone communication without disclosure of identifying information

10.7.2 Example – Washington DC

Within 72 hours of the Original Interview, the investigating (Ix) DIS will record in the OP’s STD*MIS file that the OP had a “PARTNERS INTERNET” risk factor.  Internet partners are recorded as contacts of the OP; if a partner is not listed in STD*MIS (after a search using the FIRST NAME, LAST NAME, and AKA fields), a patient record is created for him/her.  The Ix DIS should then complete a Field Record for the partner with all information pertaining to the Internet partner (including physical descriptions, identical spelling of e-mail addresses, sex venues, etc.).  The Ix DIS will then assign this partner to the IPS Coordinator (writing the IPS Coordinator’s Worker Number STD*MIS number in the Field Record).

For data entry, Ix DIS should follow this format:
Individuals who are only known by their screen name (internal e-mails) or e-mail address (external e-mails) are entered into STD*MIS as FIRST NAME: “<<SCREENNAME@WEBSITE or e-mail address>>”, LAST NAME: “INTERNET”.  Both the first and last names should be updated when more information becomes available.  The screen names will be entered followed by the website.  Note: For long screen names or e-mail addresses, simply enter as much of the name that will fit into the space (20 characters).

10.7.2.1 Examples for Internal Emails:

Website	Screenname	STD*MIS Entry
Manhunt.net	SWEATYnDC	SWEATYNDC@MANHUNT.NET
Adam4Adam.com	SWEATYnDC	SWEATYNDC@ADAM4ADAM.COM
Manhunt.net	HOTnSWEATYnDC	HOTNSWEATYNDC@MANHUNT.COM
Adam4Adam.com	HOTnSWEATYnDC	HOTNSWEATYNDC @ADAM4ADAM.COM

10.7.2.2 Examples for External Emails:

Website	Screenname	STD*MIS Entry
Gay.com	SWEATYnDC	SWEATYNDC@GAY.COM
Yahoo.com	SWEATYnDC	SWEATYNDC@YAHOO.COM
Gay.com	HOTnSWEATYnDC	HOTNSWEATYNDC@GAY.COM
Yahoo.com	HOTnSWEATYnDC	HOTNSWEATYNDC@YAHOO.COM

In addition, screen names and e-mail addresses are entered into the AKA section.  AKAs should never be changed or deleted.  New screen names must be added to the AKA section as needed.  (It is important to note that individuals can be searched for in STD*MIS by their AKA only—no other information about first or last names is needed to perform a search.)  If the name of the Internet partner becomes known at a later date, it is important that the screen name is moved to the AKA section because it will allow for the individual to be searched in the future under his/her screen name.

Individuals may change their screen names frequently, so it is essential that the date of the last known use of the screen name be noted in the Notes section (e.g., “SWEATYnDC@MANHUNT 4/19/06”).
The way we currently manage missing locating information remains the same.  For example, if we know a client’s first name and address, this individual is entered into the system as “JOHN UNK.”  Now, with this new system for entering names into STD*MIS, sexual contacts will be entered into the system as “<<SCREENNAME@WEBSITE>> INTERNET” (or “<<EMAIL ADDRESS>> INTERNET”) or, if we know the client’s first name, “<<FIRST NAME>> INTERNET.”

For data entry, IPS DIS should follow this format:
Within the Field Record, under “EVENTS”, the IPS DIS shall choose the last option: “INTERNET PARTNER NOTIFICATION”.  In the “INTERNET PARTNER NOTIFICATION” screen, there are a series of Y/N fields.  The first field, “IPS”, indicates whether the individual is an Internet partner.  The remaining 13 fields, “IPS_L1a through IPS_L4” allow for further explication of the “L” disposition that is designated for an Internet partner (see Dispositions below).

Case dispositions should be entered into STD*MIS with the following codes (STD*MIS does not allow numbers to be entered after letter codes; this can be noted in the case file):

Code	Description
A	Preventative treatment
B	Refused preventive treatment
C	Infected, brought to treatment
D	Infected, not treated
E	Previously treated for this infection
F	Not infected
G	Insufficient information to begin investigation
H	Unable to locate
J	Located, refused examination
K	Out of Jurisdiction
L	Other *
L1	Informed of specific STD exposure (2nd e-mail, phone call, in-person communication)
a	Informed of specific STD exposure, claims preventive treatment
b	Informed of specific STD exposure, refuses preventive treatment
c	Informed of specific STD exposure, claims to be infected and treated
d	Informed of specific STD exposure, claims to be infected and not treated
e	Informed of specific STD exposure, claims to be previously treated
f	Informed of specific STD exposure, claims to not be infected
g	Informed of specific STD exposure, no further contact
L2	Informed of an STD exposure (first e-mail)
L3	Not informed of STD exposure
Refused—E-mails not read even though patient logs in
Refused—Patient blocks IPS screen name
Not known if e-mails are read
Unable to locate (Patient has not logged in during Field Investigation period.)
L4	Insufficient information to begin investigation (Screen name does not exist.)

* The L disposition will be used for Internet disposition codes, provided the Internet partner does not have any physical locating information (i.e., name and/or address).  If physical locating information is acquired at any point throughout IPS, traditional disposition codes (A-K) shall be used.