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Public Health Nursing Practice Manual

INSTRUCTIONS FOR PHN TB FOLLOW-UP

The progress note format follows the correct protocol for nursing documentation: subjective, objective, assessment and plan.

  • 1.

    Enter the date of the home visit or telephone call. Indicate the type of contact.

  • 2.

    Enter who you spoke with - client, family member, etc.; the last PMD visit; the next PMD visit.

  • 3.

    Document any new medical concerns or questions.

  • 4.

    Document any discussion regarding the TB regimen - meds, MD visits, necessary tests, etc.

  • 5.

    Indicate any psychosocial problems or give updates on known difficulties.

  • 6.

    Medication toxicity review is to be documented each visit: i.e., adverse s/s denied or list adverse s/s occurring.

  • 7.

    Indicate if the pill count is not necessary: i.e., client is on DOT.

  • 8.

    This information is necessary to determine if the client is compliant with medications. Total days refers to the number of days from the previous count to the current count.

  • 9.

    Complete the information regarding the TB meds and indicate if the count is correct, “Y” or not “N”. May record any comments about the count. All the information requested is necessary to accurately complete the med. count: refill date, quantity, previous count and today’s count.

  • 10.

    May enter other objective information.

  • 11.

    Document your assessment based on information gathered at the home visit or other client contact (phone, workplace, etc.).

  • 12.

    Indicate if TB education given and if med. toxicity reviewed.

  • 13.

    Enter the person who should be called by the client. This is very important if the PHN is going on vacation, off for an extended time or has a change of assignment.

  • 14.

    Document any referrals given or other comments. Indicate if the progress note/chart is sent for review- PHNS/Clinician. (Clinicians are to review PMD cases monthly following the home visit.)

  • 15.

    PHN is to print his/her name.

  • 16.

    PHN is to sign the progress note and imprint the client’s ID.

  • 17.

    Document visit on monthly PHN TB Follow-up Form within 2 working days.

© 2007 LAC DPH Public Health Nursing

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