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MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Year

PLANNING

Documents client specific plan that is selected from the PHN Practice Manual (pp. C3 – C4).

COMMENTS:

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual (p. C5).

  • 2.

    Documents health teaching/counseling (p. C5).

  • 3.

    Refers client as needed (p. C5).

  • 4.

    Conducts surveillance of client as indicated (p. C5). (Surveillance describes and monitors health events through ongoing & systematic collection, analysis, and interpretation of health data).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

COMMENTS

F 14

April-Sept

Acute Communicable Disease Standard of Practice Evaluation Form: Individual

Circle appropriate period

Oct-March

PHN

__________________________

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