Sexually Transmitted Diseases  >  Program Guidelines  >  Medical and Laboratory Services

Program Operations Guidelines for STD Prevention
Medical and Laboratory Services

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Sections on this page:

• INTRODUCTION ML-1
• Accessibility
• Range of Services
• Clinic Environment
• Registration Process
• Clinic Flow
• Medical Records

INTRODUCTION  ML-1

High quality, accessible medical and laboratory services are essential elements in the prevention of sexually transmitted diseases within any community. While private providers, managed care agencies, and institutions such as emergency rooms and correctional facilities have become increasingly central to STD screening, diagnosis, and treatment services, categorical STD clinics remain an important source of accessible, affordable, and expert clinical care in most communities. With the integration of HIV testing, counseling, and treatment into routine STD care, the demand for services in STD clinics has increased. Therefore, it is important to examine all elements of clinic operation, from administration to the range and quality of services offered since they affect the ability of an STD clinic to play a crucial role in disease intervention. Though this chapter specifically addresses guidance for STD clinics in providing medical services, much of the information is relevant to any STD service provider or agency.

ACCESSIBILITY

The most common reasons given by clients for choosing an STD clinic for care are the availability of walk-in services or same-day appointments, lower cost of care, privacy or confidentiality concerns, convenience of the clinic's location, and expert care (Celum, 1997). Medical services at the public STD clinic should be low or no cost, confidential, and convenient to avoid the creation of barriers between the patient and the accessibility of services. It is important that the clinic be easily accessible by public transportation and the hours of operation should be varied and flexible to avoid long waiting times and turning patients away (Landry, 1996; Beilenson, 1995). This can be accomplished by evaluating waiting times and the number of patients turned away. To make services accessible, clinics should develop systems that provide walk-in services and same day appointments, remain open during lunchtime hours, provide services outside standard business hours (evening and Saturday services), and accommodate patients with immediate scheduling needs e.g., return visits and symptomatic patients, by operating at least three days a week. If a clinic is unable to provide services three days a week, a referral system should be in place so that persons needing immediate services can be accommodated. Expansion of clinical services, including the addition of evening hours, leads to an increase in overall clinic attendance and increased numbers of STD cases diagnosed (Lyttle, 1994; Hart, 1992). Despite convenient hours, outreach activities may be needed to access specific at-risk populations and should be strongly considered. For example, collaboration with a drug services program may be more likely to result in delivery of STD services to clients (Coutinho, 1987; Van den Hoek, 1997). The general public should be able to easily determine how to obtain specialized STD services. This can be done through listing the clinic in the telephone directory and among frequently called numbers or under a heading that is readily understandable to patients through advertising in locations and through media utilized by high-risk populations, listing in community medical resource directories, and providing automated telephone services to provide information about clinic hours to after hours callers.

 

RANGE OF SERVICES

STD clinics should provide basic STD prevention services emphasizing the particular needs of the at- risk populations within the community. At a minimum, clinics should be able to diagnose and treat syphilis (all stages), gonorrhea, chlamydia, bacterial vaginosis, trichomoniasis, and candida. Ideally, clinics should also be able to diagnose and treat genital warts and genital herpes, vaccinate for viral hepatitis, and perform Pap smears and pregnancy tests. Other services such as integrating HIV-related services and family planning services into routine STD services may lengthen the clinic visit, but may also address important patient needs. Condoms and primary prevention counseling should be provided at all STD clinics to help in the prevention and control of disease. A procedure should be established to accord priority care to any patient referred by a DIS, receiving HIV prevention counseling, or returning for follow-up examinations with an appointment. STD programs should also be prepared to handle the increased volume of patients that may occur with any outbreaks (see the Outbreak Response Plan chapter for details).

 

CLINIC ENVIRONMENT

The quality of the physical facility as well as the professional attitudes of staff influence a patient's impression of services. Distinct public health benefits can come from maintaining an aesthetically pleasing and professional environment. The environment should reinforce confidentiality and support health education directed toward positive behavior change.

 

REGISTRATION PROCESS

Registration is a critical component of an efficient and successful clinic. A well-trained clerical staff and a well-organized clerical system expedite patient flow at this critical point. Registration personnel see patients first; therefore, they set the tone for the visit and must be aware of their role in influencing patient attitudes.

Clinical, counseling, or other services must never be denied because a patient is unable or declines to provide identification. Patient address and locating information should be updated at every visit in the event that follow-up is needed. When a substantial proportion of patients needing follow-up testing, treatment, or disease intervention services cannot be located because of false identities or addresses, the clinic should strongly consider other methods to insure follow-up, including a policy of requesting identification at registration. It may be useful to have a supervisor speak with patients who cannot provide identification to explain the importance of obtaining accurate information for the purpose of follow-up. Clinics that offer anonymous HIV antibody counseling and testing should advertise a waiver of positive identification for persons seeking that service only.

Clinics should have some system of "fast-track" registration, such as assigning letters instead of numbers, for persons who have priority referrals or who re-visit. The DIS referred or "expected-in" file should be checked each time a person registers for STD services to ensure that persons who have been referred by a DIS for examination, or those who need repeat serologic testing or HIV counseling are identified and receive these services. The "expected- in" file contains a brief summary of treatment or other information on persons needing follow-up for disease intervention services. The file may include the following: persons with positive STD/HIV test results in need of treatment, persons referred either by the STD clinic or other facilities, sex partners or cluster suspects/associates of diagnosed patients, and persons who need special repeat testing. With the registration staff attaching the expected-in form to a medical chart, a clinician will have additional epidemiologic information and medical information needed to provide immediate and appropriate treatment.

CLINIC FLOW

Clinic flow should facilitate the effective use of personnel and physical facilities while preserving confidentiality, dignity, and excellent medical care. Clinics should routinely evaluate space and financial resources critical to providing adequate services. The sequence of services should be logical so that confusion or unnecessary delays for patients are avoided; emphasis should be placed on staff moving when necessary so that patients make as few moves as possible. Special stops (such as venipuncture or treatment) often become a bottleneck. They tend to compromise efficient clinic operation with delays for patients because of the need for specialized staff, separate rooms, and separate waiting areas. Individual clinicians can safely perform venipuncture in the examination room if they observe universal precautions. In any case, the initial patient visit should take no more than 1.5 hours from registration to treatment. (This does not include STD/HIV interview sessions, partner services, or special circumstances which will vary in length depending on the STD diagnosis and individual patient needs.)

 

MEDICAL RECORDS

The format, composition, and maintenance of medical records are crucial. Review of the medical records can determine whether the records are properly maintained and documented, as well as whether clinicians are consistently following established protocols, thus ensuring high quality care for patients. Clinics that provide testing, treatment, and other early intervention services for HIV infection will need to collect additional information. Additional information on medical records should include HIV risk assessment, drug use, relevant sexual history, contraceptive use, condom use, recent travel outside the U.S., hepatitis B vaccination history, whether counseling was provided, and plans for follow-up or referral. In areas of high HIV prevalence, additional information may be included such as history of tuberculosis (including exposure and infection).

It is important that medical records contain sufficient demographic information to identify and locate patients promptly and contain accurate information on symptoms, medical history, physical examination findings, laboratory tests, diagnoses, and treatment. Brief narrative descriptions should accompany items needing additional explanation or to document other relevant information.

Medical records contain important and confidential information. They should be stored in locked files or locked rooms that are easily accessible to clinic personnel but inaccessible to unauthorized persons. It is important that medical records that are related to cases being managed by DIS be readily accessible to the DIS. Medical records should be removed from desk tops and filed in locked desk or file drawers at the end of each day. Computerized medical records also need to have rigorous access protection procedures to prevent unauthorized entry into the file, as well as back-up filing to prevent the loss of information.

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