Public Health Nursing Practice Manual
Instructions for PHN TB Class 3/5 Assessment Form
Date TB medications reviewed with client and family (if any)/initial of person providing TB meds review.
Date side effects of TB meds reviewed with client and family (if any)/initial of person reviewing TB meds side effects. Instructions about whom to call if client experiences problems to be provided verbally and in writing- write name/phone number provided.
Date importance of adherence to TB regimen and consequences of non-adherence explained to client and family/ initial of person providing adherence education. Clarify consequences, for example, PHI may be involved or MDR may develop.
Date instructions regarding where to call if unable to keep appointment provided/initial of person providing instructions.
Check referrals provided, date referrals provided, and initial of person providing referrals.
After initial contact, provide information regarding next TB follow-up appointment- date/initial of person writing-in information.
Write-in any other plan and date and initial.
End of each page
1. At bottom of each page, initial/print name/signature of PHNs who completed the form. If more than one PHN was involved, all must sign.
2. Place client’s addressograph in bottom right corner.
© 2007 LAC DPH Public Health Nursing