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Public Health Nursing Practice Manual

PHN TB FOLLOW-UP FORM

COUNTY OF LOS ANGELES

DEPARTMENT OF PUBLIC HEALTH

1 Date:

PHN TB Follow-up

2

Subjective:

3 Medical Review: 4 TB Regimen Review: 5 Psychosocial Review: 6 Medication Toxicity Review: 7 Objective - TB Pill Count

Home Telephone

Last MD Visit:

Office

Clinic

Next MD visit:

N/A

8 Date of Previous Count:

9 Current TB Meds/dosage

Isoniazid Rifampin Rifamate Ethambutol Pyrazinamide Vitamin B6

Refill date

Quantity

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Y

N

Previous Ct

Total Days: Today’s Ct

Today’s Date:

Correct Ct/ Comments

13 10 Other Objective Info: 11 Assessment Other Assessment: Plan 12TB Education Reviewed: Client/family to call 14 Referrals/Comments:

Yes

No

Adherent

Med.Toxicity Reviewed: if problems or concerns.

Yes

Non-Adherent

No

15 PHN Name (print) 16 PHN Signature

© 2007 LAC DPH Public Health Nursing

E 22

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