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STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Acute Communicable Disease Standard of Practice Evaluation Form: Individual

Circle appropriate period

Oct-March

PHN

__________________________

POPULATION DIAGNOSIS AND PRIORITIES

1. Documentation indicates medical diagnosis (p. C2).

N/A

MET

NOT MET

MET

MET

NOT MET

N/A

NOT MET

N/A

  • 2.

    Priority of follow up documented

    • (p.

      C2) as outlined in the PHN Practice Manual (p. D1) or as determined in consultation with the PHNS.

COMMENTS:

OUTCOMES IDENTIFICATION

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

Documents health needs/goals for specific need(s) identified (p. C2).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

April-Sept

Year

COMMENTS

F 13

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