Instructions - POC Form

October 2020

Instructions for Point of Care Testing Form (CDC 57.155)

Data Field	Instructions for Data Collection/Entry
Facility ID	The NHSN-assigned facility ID will be auto-entered by the computer.
Type of Individual Tested	Required. From the drop-down menu, choose whether the testee is a resident of the facility or a staff/volunteer/contractor at the facility.
Resident ID	Conditionally Required. If the testee is a facility resident, enter the alphanumeric resident ID. This is the resident identifier assigned by the facility and may consist of any combination of numbers and/or letters. This should be an ID that remains the same for the resident across all admissions and stays.
Staff ID	Conditionally Required. If the testee is a staff/volunteer/contractor at the facility, enter an alphanumeric staff ID number. This is a number assigned by the facility and may consist of any combination of numbers and/or letters.
Name	Required. Enter the first, middle, and last name of the individual tested.
Gender	Required. Check Female, Male, or Other to indicate the gender of the individual tested.
Date of birth	Required. Record the date of the individual’s birth using this format: MM/DD/YYYY.
Ethnicity	Required. Specify if the individual is either Hispanic or Latino, or Not Hispanic or Not Latino. This data should be based upon the individual respondent’s self-identification with regards to ethnicity.
Race	Required. Specify one or more of the choices below to identify the individual’s race: American Indian/Alaska Native Asian Black or African American Native Hawaiian/Other Pacific Islander White This data should be based upon the individual respondent’s self-identification with regards to race.
Address, line 1	Required. Enter the street number and name or P.O. Box for the testee. If the testee is a resident, the address will auto-populate with the facility’s address.
Address, line2	Conditionally Required. Enter any secondary address information for the testee such as suite number. If the testee is a resident, the address will auto-populate with the facility’s address.
City	Required. Enter the city of residence for the testee. If the testee is a resident, the address will auto-populate with the facility’s address.
State	Required. Enter the state of residence for the testee. If the testee is a resident, the state will auto-populate with the facility’s state.
Zip Code	Required. Enter the zip code for the testee’s residence. If the testee is a resident, the zip code will auto-populate with the facility’s zip code.
County	Required. Enter the county of the testee’s residence. If the testee is a resident, the address will auto-populate with the facility’s county.
Contact Phone	Required. Enter the phone number for testee. If the testee is a resident, the field will auto-populate with the facility’s phone number.
Ext	Optional. Enter any extension for the phone number of the testee. If the testee is a resident, the extension will auto-populate with the facility’s extension if one is specified for the facility.
Test Date	Required. Use the calendar option presented to indicate the date on which the specimen was tested, or enter the date manually using format: MM/DD/YYYY.
Device Name	Required. Field will auto-populate with the testing device which has been identified as the default device. If a device different from the default device was used, then choose that device from the drop-down menu. To change the default device for future test results, choose “Choose Default” from the POC Test Result screen, choose the new POC default device from the drop-down menu and choose Save as Default.
Specimen Source	Required. Choose the most accurate source for the specimen from the available choices. Choices presented will include only those acceptable for the type of POC device used and may include one or more of the following: Nasal Swab or Nasopharyngeal Swab.
Test Result	Required. Choose from one of the test results provided by the device in use and listed in the drop-down menu. Choices for the devices are as follows: Abbott BinaxNOW COVID-19 Ag Card Negative Positive Invalid result or Specimen unsatisfactory for evaluation Quidel Sofia 2 SARS Antigen FIA Detected Not detected INV - Invalid result or Specimen unsatisfactory for evaluation BD Veritor System for Rapid Detection of SARS-CoV-2 Positive Test for SARS-CoV-2 (antigen present) (Detected) Presumptive Negative Test for SARS-CoV-2 (no antigen detected) (Not Detected) Test Invalid. Repeat the test (Invalid result or Specimen unsatisfactory for evaluation)
Specimen Number	Required. The NHSN application will auto-populate this field with an incrementally identified number. However, if desired, a facility may edit the data field to record a different number assigned to the specimen.
Ordering Physician	Required. From the drop-down menu, choose name of physician ordering the test. The drop-down menu will have been populated by data previously provided by the facility via the Setup Physicians option in POC Test Result section.
Was person symptomatic?	Required. Enter Yes if testee had symptoms of COVID-19 at the time of the test. Enter No if testee was without symptoms. Enter Unknown if it is not known whether the testee had symptoms at the time of test.
Was person pregnant?	Required. Field will auto-populate with No. Edit field to Yes if testee was pregnant at the time of symptoms. Edit field to Unknown if pregnancy status is not known.
Address, line 1	Optional. Enter the street number and name or P.O. Box for the ordering physician’s place of practice. This may be the same as the facility’s address.
Address, line2	Optional. Enter any secondary address information, such as suite number, for the ordering physician’s place of practice. This may be the same as the facility’s address.
City	Optional. Enter the city of the ordering physician’s place of practice. This may be the same as the facility’s address.
State	Optional. Enter the state of the ordering physician’s place of practice. This may be the same as the facility’s address.
Zip Code	Required. Enter the zip code of the ordering physician’s place of practice. This may be the same as the facility’s address.
County	Optional. Enter the county of the ordering physician’s place of practice. This may be the same as the facility’s address.
Work Phone	Optional. Enter the phone number for the ordering physician’s place of practice, including area code. This may be the same as the facility’s phone number.
Ext	Optional. Enter any extension for the phone number of the ordering physician’s place of practice.

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