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Public Health Nursing Practice Manual

PLAN

Date/ Initial

1H290 registration submitted 2H304 of client submitted (complete per protocol requirements). 3H289/ interview of index re: contacts initiated 4H304(s) for contact(s) initiated 5H289 and H304(s) of out of district contact(s) referred to district of residence

6H289 and dispositioned H304(s) submitted 7H290 confirmation submitted 8Work/school contact follow up initiated R e f e r r e d t o : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ or H513 closure submitted ___________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( s e e H 2 8 9 )

9Information/education about TB, TB treatment regime, and contact follow up given verbally and in writing to client and

family/household (if any).

TB literature provided in the appropriate language of the client.

10Client advised about communicability. Techniques to prevent transmission were explained to client and family/household (if any). 11If home isolation indicated, home isolation explained to client/family/household (if any) and all agree to adhere to it until informed

by the PHN/MD that it is no longer required.

ο Client verbalizes understanding and agreement.

12TB medications reviewed with client and family (if any) and correct method for taking them was reviewed.

13TB meds side effects explained to client. C l i e n t t o _ _ _ _ _ _ _ _ _ _ c a l l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

if problems.

ο Information given in writing.

14Importance of adherence to TB regime and consequences of non-adherence explained to client and family (if any). 15Explained to client that if unable to keep appointment(s), client to call: ______________________________________

16Action/Intervention:

Prenatal Care

Family Planning

WIC

Food

Breastfeeding

Nutrition Counseling

Pediatric Primary Care

CHDP

Immunization

Regional Center

Parenting Class CCS Dental Care Safer Sex Practices Day Care Vision Care Communicable Disease PCG NFP Exercise Drug/ETOH Treatment Transportation Smoking Cessation Shelter/Housing Environmental Health Legal Aid Family Violence referral: Building & Safety DPSS Clothing DCFS ________________________________________________________ Counseling/Mental Health referral: _______________________________________________________

Medical Care at H e a l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ t h y F a m i l i e s w o r k e r a t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Public Health Clinic at Medi-Cal worker at

_________

Other

______________________________ ____________________ ____________________________________________________________________________

Bottle Caries

Smoking/Chem. Dep.

Safer Sex Practices

Back to Sleep

Anticipatory Guidance given about:

Exercise

Immunization

Safety/Injury Prevention

Folic Acid

Healthy Diet

Pre-Conception Counseling

O t h e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

C o m m e n t s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

17 Next TB Clinic Appointment: 18Other Plan:

_________________

Next PMD Appointment:

_____________________

Other Plan:

Comments/ Date:

____ _________________________

_______________________

Initial

Print Name/Title

Signature/Title

____ _________________________

Initial

Print Name/Title

© 2007 LAC DPH Public Health Nursing

________________________

Signature/Title

E 20

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