Bloodborne Pathogen Exposure Evaluation Note (Needlestick/Body Fluid)

Date/Time of Encounter: [Date and time of clinical evaluation]

Date/Time of Exposure Incident: [Date and time of exposure, or "Unknown" with brief explanation] (If exposure time is unavailable, document "Unknown" with a brief explanation rather than leaving blank.)

Exposure Location: [Unit/department/facility]

Employee Name: [Full name]

Employee DOB: [MM/DD/YYYY]

Job Role/Department: [Role and department]

Source Individual: [Name and MRN if known, or "Unknown source" with brief explanation] (Keep source details minimal and limited to information relevant for exposure management.)

Incident Report Number: [Number or "Not available"]

Chief Complaint

[Reason for evaluation including exposure type and anatomical site] (One concise line.)

History of Present Illness

[Narrative description of exposure incident] (Describe what procedure/task was occurring, how the exposure happened, what body fluid was involved, and immediate first aid performed. Keep concise.)

Exposure Route: [percutaneous / mucous membrane-eyes / mucous membrane-mouth / non-intact skin]

Body Fluid: [blood / visibly bloody fluid / other OPIM—specify]

Device/Object: [Device type, gauge if known, safety device status, whether in vein/artery] (Examples: hollow-bore needle, suture needle, scalpel, glass.)

Injury Severity: [Depth of puncture/laceration, whether bleeding occurred, whether device was visibly bloody]

PPE in Use: [Gloves / eye protection / mask / gown / none]

First Aid Performed: [Description of wound cleansing/irrigation and duration]

Time from Exposure to Evaluation: [Calculated time in hours/minutes]

Source Individual Assessment

Source Availability: [known source with consent / source refused testing / source unavailable / unknown source]

Known Source Status (if available):

• HIV: [positive / negative / unknown] (If positive, note whether on ART and whether viral load documented as undetectable, with date.)
• HBsAg: [positive / negative / unknown]
• HCV: [RNA positive / RNA negative / anti-HCV positive with RNA pending / anti-HCV negative / unknown]

Source Testing Ordered: [Tests ordered with indication of rapid vs. standard testing and status: pending/final]

[Environmental context and risk discussion for unknown source] (Include only for unknown source exposures. Document available environmental information and note that risk assessment used shared decision-making given incomplete information.)

Exposed Employee Assessment

Current Symptoms: [None / anxiety / nausea / other—specify]

Relevant Medical History: [Renal disease / liver disease / immunocompromise / none relevant]

Current Medications: [List all medications]

Allergies: [Medication and vaccine component allergies]

HBV Vaccination History: [Number of doses and dates if known] (If records unavailable, document: "Employee reports vaccination but documentation unavailable; anti-HBs ordered to confirm immune status.")

HBV Immune Status: [documented responder with anti-HBs ≥10 / unknown response / documented non-responder after 2 series / unvaccinated or incomplete series]

Baseline HIV/HBV/HCV Status: [Prior results if known, with dates]

Pregnancy/Breastfeeding Status: [Patient denies pregnancy / pregnant—gestational age / breastfeeding / not applicable] (Omit for male employees.)

Current PrEP Use: [On oral PrEP—specify regimen / received long-acting cabotegravir within past year—specify date / not on PrEP]

Review of Systems

• Fever: [present / absent]
• Rash: [present / absent]
• Sore throat: [present / absent]
• Lymphadenopathy: [present / absent]
• Myalgias: [present / absent]
• GI symptoms: [nausea / diarrhea / abdominal pain / absent] (Include if on PEP.)
• Headache: [present / absent] (Include if on PEP.)

Physical Examination

• General: [Appearance and affect]
• Injury Site: [Location, wound characteristics, signs of infection]
• Mucous Membranes: [Eye or oral findings—conjunctival injection, lesions, irritation] (Include only for mucous membrane exposures.)

Assessment

1. Occupational Blood/Body Fluid Exposure

[Summary of exposure route, fluid type, device characteristics, and overall risk stratification] (Explicitly state whether this constitutes a true exposure requiring evaluation versus negligible-risk contact.)

2. HIV Exposure Risk and PEP Decision

[Source HIV status and exposure severity factors including deep injury, hollow-bore needle, visible blood, device in vessel] (Document shared decision-making discussion when source is unknown, source viral load is undetectable, or employee is on PrEP.)

Decision: [PEP initiated / PEP offered and declined / PEP not indicated] — [Rationale]

3. HBV Exposure Risk and Prophylaxis Decision

[Employee HBV immune status category and source HBsAg status]

Decision: [HBIG indicated / vaccine dose indicated / no prophylaxis needed] — [Rationale]

4. HCV Exposure Risk

[Source HCV status]. No post-exposure prophylaxis available per current guidelines; management is testing-based follow-up.

Plan

Testing

Employee Baseline Testing:

• HIV 4th-generation Ag/Ab: [ordered / result] [pending / final]
• Hepatic panel (AST, ALT): [ordered / result] [pending / final] (Include if PEP initiated.)
• Serum creatinine: [ordered / result] [pending / final] (Include if PEP initiated.)
• HCV antibody with reflex to RNA: [ordered / result] [pending / final]
• HBV serologies: [Specify tests—HBsAg, anti-HBs, total anti-HBc] [ordered / result] [pending / final]

Source Testing: [Tests ordered or results if available, with rapid vs. standard and status]

HIV Post-Exposure Prophylaxis

Indication: [Why PEP is or is not warranted based on source status and exposure severity]

Regimen Prescribed (28 days): [Drug names, doses, frequency]

Time of First Dose: [Date/time; calculated interval from exposure]

Drug Interaction Review: Completed. [Notable interactions and actions taken, or "no significant interactions identified"]

Side Effect Counseling: [Key points discussed]

Instructions: Discontinue PEP if source confirmed HIV-negative. Adherence guidance provided.

(If PEP declined, document: Risks and benefits explained; employee demonstrated understanding. Direct quote: "[Employee statement]")

(For employees on PrEP or who are pregnant/breastfeeding, document specific counseling and ID consultation if obtained.)

HBV Post-Exposure Prophylaxis

• HBIG: [Administered—dose, timing, lot number / not indicated]
• HBV Vaccine: [Product and dose number in series administered / not indicated] (Include schedule for series completion if applicable.)
• Follow-up Serology: [Timing for anti-HBs testing; note delayed testing if HBIG given]
• Rationale if none given: [Reason no prophylaxis needed]

HCV Management

No post-exposure prophylaxis per current guidelines. Follow-up testing per schedule below. If HCV RNA positive, referral to hepatology/infectious disease for treatment evaluation.

Counseling Provided

• Transmission risk explained in context of this specific exposure
• PEP adherence instructions: importance of completing 28-day course; what to do if dose missed (Include if PEP initiated.)
• Secondary transmission precautions until final HIV testing: barrier protection; no blood/tissue/organ donation
• Warning signs requiring urgent evaluation: fever, rash, severe abdominal pain, jaundice, dark urine
• Work status: [No restrictions due to exposure / restrictions—specify]
• Written instructions provided

Follow-Up Schedule

(Convert to specific target dates when exposure date is known.)

• Within 72 hours: Re-evaluation for PEP tolerability, review source results, additional counseling (Include if PEP initiated.)
• HIV Testing: Week 12: HIV Ag/Ab plus NAT (final test). Interim testing at weeks 4–6 only if PEP started >24 hours post-exposure or doses missed.
• HCV Testing: Weeks 3–6: HCV RNA. Months 4–6: HCV antibody with reflex to RNA if earlier RNA negative.
• HBV Testing: [Timing for anti-HBs based on immune status and prophylaxis; note delayed testing if HBIG given]
• Vaccine Appointments: [Target dates for subsequent HBV vaccine doses if series initiated] (Include if applicable.)
• Responsible Clinic: [Occupational Health / Employee Health / Primary Care / Infectious Disease]

Administrative

Separate employer-directed written opinion will be provided per OSHA requirements. This clinical note contains confidential medical information not to be shared with employer.

Refusals or Special Circumstances

(Include this section only if applicable; otherwise omit entirely.)

• Employee Declined: [Testing / prophylaxis / follow-up—specify]. Risks and benefits explained; employee demonstrated understanding and capacity. Alternative plan: [plan offered]. Direct quote: "[Employee statement]"
• Source Refused Testing: [Document refusal and impact on risk assessment and management decisions]
• Late Presentation: [Hours from exposure to evaluation; rationale for management decision regarding PEP eligibility]