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Public Health Nursing Practice Manual

Encounter (circle)

1

2

3

4

date

____

Home

Office

Telephone

Other

PLAN Health Need/Goal:

Health Need/Goal: Health Need/Goal: Health Need/Goal:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Breastfeeding

Day Care

Family Planning

Parenting Class

Safer Sex Practice

Building & Safety

DCFS

Food

PCG

Shelter/Housing

CCS

Dental Care

Immunization

Ped. Primary Care

Smoking Cessation

CHDP

DPSS

Legal Aid

Physical Activity

Transportation

Clothing

Drug/ETOH Tx

NFP

Prenatal Care

Vision Care

Comm. Disease

Environ. Health

Nutrition Counseling

Regional Center

WIC

ACTION/INTERVENTION given:

Counseling/Mental Health referral:

___________________________________________________________

F a m i l y V i o l e n c e r e f e r r a l : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ H e a l t h y F a m i l i e s w o r k e r a t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Medi-Cal worker at _ _ _ _ M e d i c a l a r e a t _ _ _ _ C _ _ _ _ _ _____________ Public Health Clinic at _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _________________

Other

_________________________________________________________________________________

Back to Sleep

Bottle Caries

Physical Activity

Folic Acid

Nutrition Counseling

Immunization Other

Pre-Conception Counseling

Safer Sex Practices

Safety/Injury Prevention

Smoking/Chem. Dep.

Anticipatory Guidance Given About:

Nutrition/ Physical Activity Counseling/Referral:

Comments

________________________________________________________________________________

Comments

_________________________________________________________________________________

Time:

_ _ _ _ _ _ _ _ _

DISPOSITION On-going Level 1 intervention; next contact (date/purpose) _______________________________________________

Close--Level 1 Level 2 intervention needed; next contact (date/purpose) _________________________________________ other reason _________________________________ Close Close Individual/Family declines further service UTL moved within LA County jurisdiction (complete transfer section below) moved outside LA County jurisdiction

Transfer to

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Client Satisfaction form given:

yes

no

P H N _ _ _ _ _ _ _ _ ( p r i n t ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

P H N _ _ ( s i g n ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e

___________

(For Closure Only)

i n t ) _ _ _ _ _ _ _ _ P H N S ( p r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

P H N S ( s i g n ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e

___________

© 2007 LAC DPH Public Health Nursing

E5

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