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Public Health Nursing Practice Manual

Instructions for PHN TB Class 3/5 Assessment Form

Topic

Plan (Cont.)

Guidance

  • 12.

    Date TB medications reviewed with client and family (if any)/initial of person providing TB meds review.

  • 13.

    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.

  • 14.

    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.

  • 15.

    Date instructions regarding where to call if unable to keep appointment provided/initial of person providing instructions.

  • 16.

    Check referrals provided, date referrals provided, and initial of person providing referrals.

  • 17.

    After initial contact, provide information regarding next TB follow-up appointment- date/initial of person writing-in information.

  • 18.

    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

E 13

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