COVID-19 Guidance: Health Report Documentation Quick View
Upload lab
Scenario
A. Symptomatic UAC with COVID-
related symptoms
B. Asymptomatic UAC tested for
COVID-19 at the Initial Medical
Exam (IME) or at an Establish
Care/Well-Child Check Visit
C. Asymptomatic UAC tested for
COVID-19 prior to a health
procedure or hospital admission
D. UAC potentially exposed to a
suspect or lab-confirmed
individual (UAC & Non-UAC)
E. Asymptomatic UAC tested for
COVID-19 per health
department/agency/program
protocol, but did not have an
exam by an MD/DO/NP/PA
F. UAC who requires isolation upon
admission due to positive
/pending COVID-19 lab result in
DHS custody
Working
Report Type Final Diagnosis COVID-19 Lab Info result (“Lab
Diagnosis
Test” File Type)
• IME report if symptoms were first 1. If lab is positive, confirm
reported at IME COVID-19 diagnosis
Enter in “Potentially Reportable
• Medical Complaint report if symptoms 2. If lab is negative, rule
COVID-19 Infectious Disease (Non-TB) Lab Yes
were reported after IME out COVID-19 diagnosis
• Update Visit report if testing was Testing” panel
& replace with
performed after an alternative diagnosis given by HCP
diagnosis was made (e.g., Influenza/ILI)
1. If positive lab, add &
• IME report if screening was done as No COVID-19 confirm COVID-19 Enter in “Potentially Reportable
part of IME when entering Infectious Disease (Non-TB) Lab Yes
diagnosis
• Medical Complaint report for Establish report Testing” panel
2. If negative lab, no
Care/Well-Child Check Visit
COVID-19 diagnosis
1. If positive lab, add &
Add lab info to existing report with No COVID-19 confirm COVID-19 Enter in “Potentially Reportable
diagnosis that requires procedure / when entering Yes
diagnosis Infectious Disease (Non-TB) Lab
admission or to Update Visit report report
2. If negative lab, no Testing” panel
COVID-19 diagnosis
1. For UAC exposed to a non-UAC with 3. If asymptomatic & tested for COVID-
COVID-19, enter a Contact 19, enter lab info into CI report; if
Investigation report through the positive, select an “Outcome” of Cannot upload
minor’s UAC Health Screen Diagnosed with illness & follow files to CI report;
N/A N/A
2. For UAC exposed to another UAC Scenario B, Medical Complaint upload to IME or
with COVID-19, enter a Contact report another report
Investigation report through the 4. If UAC develops symptoms & is
case’s “Illness of Public Health tested, follow Scenario A, Medical
Concern” panel Complaint
Contact Investigation Report
Enter into CI report; if positive, select Cannot upload
(Note: Enter reason for testing in
an “Outcome” of Diagnosed with illness files to CI report;
“Relationship to case” field, ex. N/A N/A & follow Scenario B upload to IME or
Voluntary Departure, testing per CBP
another report
request)
Medical Complaint report (Note: COVID
Confirm COVID-19 Enter in “Potentially Reportable
diagnosis should not be entered into COVID-19 Infectious Disease (Non-TB) Lab Yes
diagnosis
IME, as well) Testing” panel
 COVID-19 Guidance: Health Report Documentation Details

Signs/Symptoms

Scenario A, D4, and F

Document signs/symptoms reported by the UAC or as observed and reported by the ORR care provider or foster parents to the HCP during the exam in the
Review of Systems (ROS) field. Ensure that the HCP addresses all signs/symptoms reported by the child or caregiver and obtains an accurate, or best estimate,
onset date for each sign/symptom.
Working Diagnosis

Scenario A, B1, C1, and F

Check the “COVID-19” option under the “Potentially Reportable Infectious Disease” category in the Working Diagnosis field. Do NOT check “Other” and write in
different versions of the COVID-19 diagnosis (e.g., R/O Coronavirus, suspect COVID, COVID-19 exposure).
COVID-19 Lab Testing Information

Scenarios A, B, C, and F

Enter all diagnostic testing related to the COVID-19 work-up into the Potentially Reportable Infectious Disease (Non-TB) Lab Testing section on the day the
specimen was collected. Select “COVID-19” from the Disease Tested dropdown. Enter the date the specimen was collected and the source. Select “PCR” in the
Test column. Update the Result field from “Pending” once the results are known. Contact DHUC for assistance with interpreting lab results, if needed.

Scenarios D3 and E

Enter all diagnostic testing related to the COVID-19 work-up into the Lab Testing Performed field on the day the specimen was collected. Select “COVID-19”
from the Disease Tested dropdown. Enter the date the specimen was collected and select “PCR” in the Test column. Update the Result field from “Pending”
once the results return from the lab. Contact DHUC for assistance with interpreting lab results, if needed.
Final Diagnosis

Scenarios A1, B1, C1 and F

If the PCR lab result is positive, confirm the COVID-19 diagnosis in the Case Wrap-Up panel. Enter the plan details, medications, and public health interventions
(e.g., quarantine/isolation, delayed discharge). Notify DHUC if a UAC’s discharge is delayed for any health reason, including COVID-19.
Scenario A2

if the lab result is negative, rule out the COVID-19 working diagnosis and select/enter the final diagnosis given by the healthcare provider (e.g., Upper/lower
respiratory illness (Not ILI), Influenza/Influenza-like illness (ILI)).
Exposures

Scenarios D1 and E

• Click on the “+” sign next to the Contact Investigations header to expand the section on the UAC Health screen. Click on the “Add New” button.

• Select “COVID-19” from the Disease dropdown and click on the “Next” button.

• Complete all fields in the Contact Investigation form.

 Relationship to case: Enter the role of the COVID-19 patient in relation to the UAC (e.g., program staff member, foster parent).
 Date of first exposure to case: Enter the LAST date the minor was exposed to the COVID-19 patient. For quarantine purposes, it is important to
capture the day of last exposure to COVID-19. Leave this field blank if the minor is being tested in the absence of a known exposure to a COVID-
19 patient.
 Medications given: Enter medications prescribed due to the COVID-19 exposure.
 Immunization given: Select “No”.
 Lab testing performed: If a COVID-19 lab test was ordered on the potentially exposed asymptomatic UAC, select “Yes” and enter the date the
specimen was collected and the type of test performed. As this time, the only acceptable COVID-19 test method for UAC is the PCR test.
 Was child quarantined? Select “Yes” as ORR requires potentially exposed minors to be placed in quarantine.
 If quarantined, was discharge delayed: Select “Yes” if the minor was ready for discharge, but could not be discharged because s/he was
quarantined due to the COVID-19 exposure. Select “No” if quarantining the minor did not impact the discharge date.
 Outcome of ORR contact investigation: Enter the outcome of the COVID-19 contact investigation performed by ORR based on the following:
- Pending: Minor is in quarantine.
 - Incomplete evaluation: Minor was lost to follow-up prior to the end of the quarantine period (e.g., runaway, discharged, picked up by ICE).
- Cleared: Minor remained asymptomatic for the entirety of the quarantine period and has been medically cleared by the health department
and DHUC. If tested for COVID-19, minor’s test was negative.
- Diagnosed with illness: Minor was diagnosed with COVID-19 through a positive PCR test. NOTE: An auto-notification will be sent to DHUC
when this option is selected.

*** Remember to update the “Outcome of ORR contact investigation” with the final outcome (i.e., the Outcome should not be left as Pending).
Scenario D2

• Enter the contacts through the COVID-19 patient’s Illness of Public Health Concern panel. Click on the Edit icon in the Options column to open the
panel.

• Add a contact by clicking the “Add New” link in the Exposures header. NOTE: Discharged UAC who are identified as potentially exposed can be entered
up to 45 days after release/transfer.
• Enter the minor’s A# and click on the “Search” button. When the correct minor displays, click on the circle in the Select column and click the “Save”
button. Repeat this step for every contact.

• After all contacts have been added, click on the Edit icon in the Contact Investigation column of the first contact to display the Contact Investigation
form.
• Complete all fields in the Contact Investigation form. In the Relationship to case field, enter the role of the COVID-19 patient in relation to the UAC (e.g.,
Roommate, Housemate, Classmate). NOTE: The Contact Investigation report can be accessed through the contact’s UAC Health screen and the COVID-19
patient’s Illness of Public Health Concern panel.
 • After saving the Contact Investigation report, the system will automatically return to the COVID-19 patient’s Illness of Public Health Concern panel.
Complete the Contact Investigation form for each contact, answer the Health Department notification, number of exposed staff (if known), and
delayed/postponed intakes fields at the top of the panel and click the “Save” button. NOTE: Notify DHUC before intakes are stopped for a health-related
reason.

Files

All Scenarios

Upload all documentation (e.g., office notes, lab results) to the Files section of the report. Be specific in the “File Name” field, select the corresponding “File
Type” and enter relevant details in the “File Description” field. NOTE: Remove commas from the document’s name before uploading to the UAC Portal.