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Public Health Nursing Practice Manual

Instructions for PHN TB Class 3/5 Assessment Form



General Instructions

1. The assessment is to be completed for all TB 3 and TB 5 clients placed on 2 or more TB drugs.

    • a.

      If the TB 5 client is not placed on TB medications (i.e. Alien Referral), use the PHN TB 3 or TB 5 Assessment form page 1 and the PHN Assessment form.

    • b.

      If the client becomes a TB 3, complete the remaining pages of the PHN TB 3 or TB 5 Assessment form. Applicable information may be transferred from the PHN Assessment form.

  • 2.

    The assessment may be completed during several client contacts according to priority of information needed. The form should be completed within 1-2 months of initial referral depending on client variables (i.e., accessibility, cooperation). If more time is needed, PHN should confer with PHNS.

  • 3.

    Date and initial each entry as completed. Initial, print and sign name at the bottom of each page. More than one PHN may initial and sign.

  • 4.

    The comment section at the bottom of each page is to be used as needed.

  • 5.

    Imprint each page (bottom right) with the client’s addressograph.

  • 6.

    The assessment is attached to the chart under the miscellaneous section and is to replace the progress notes in documenting the initial client assessment.


1. Presenting symptoms: Indicate onset/date and duration/frequency and characteristics on symptoms checked “yes”.

2. Medical History and Past TB History: If history of hepatitis/liver disease, specify type, i.e., Hepatitis A, B, C or type of liver disease. Review of Systems – Define the problem in the remarks, i.e., diabetes – IDDM or NIDDM well or poorly controlled; GI disease, i.e., gastric ulcers, Crohn’s Disease, ileostomy; respiratory, i.e., COPD, asthma, etc.

3. Dental: Define the problem requiring care, i.e., due for exam, poor dental hygiene/caries, denture problems, mouth odor, etc.

4. Nutritional Status: Weight changes – Complete information. (May refer back to symptom/ onset info) Appetite – Complete information. (May refer back to symptom/ onset info) Review basic food groups with the client. Comments on problems found.

© 2007 LAC DPH Public Health Nursing


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