The following should be discussed and documented in the patient’s medical record:

1. Information about the source, where available (as outlined in section: Assessment of the risk of HIV transmission) 
2. Information about the exposure
   
   1. Date and time of exposure
   2. Type of exposure, including sites(s) involved, blood or body fluids involved, trauma, first aid measures applied and any contributing factors which may affect the risk assessment (See Table 2)
   3. If the act during which exposure occurred was consensual or non-consensual.
3. Information about the exposed person
   
   1. Most recent HIV test and result
   2. Previous use of PEP, frequency of PEP courses, tolerability of previous PEP courses
   3. Current use of PrEP (see Table 5 for the interface between PEP and PrEP)
   4. Other potential HIV risk exposures in the last three months
   5. Symptoms of a sexually transmissible infection (STI)
   6. Evaluation of current blood-borne viruses (BBVs). If known HBV-positive status, further discussion with a specialist in HBV management should occur as outlined in section: Management of possible exposure to other conditions: Hepatitis B However, this discussion should not delay the commencement of PEP
   7. Current pregnancy and gestation, pregnancy risk, use of contraception (consider emergency contraception) and current lactation
   8. Medical history.
4. HIV – informed consent for testing

HIV testing must be performed before prescribing PEP, see Table 4.

• Informed consent is required for all pathology testing (including HIV) and can be given verbally. Written consent is not required. 
• Informed consent must include the clinician providing information and checking the patient understands the test, the reasons for being tested, and the potential implications of not being tested. 

For more information on HIV testing, see the National HIV Testing Policy.