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Acute Communicable Disease Standard of Practice Evaluation Form: Individual

PHN

__________________________

Circle appropriate period

Oct-March

STANDARD ELEMENTS

EVALUATION

  • 1.

    Documentation reflects consideration of client’s needs in determining interventions and/or on-going revisions of the plan of care (p. C5).

  • 2.

    Documents client understands the disease process and prevention of transmission (p. C5).

  • 3.

    Initiates action for non-adherent client/contacts (p. C6).

  • 4.

    Follows up with non-adherent client/contacts (p. C6).

  • 5.

    Completes forms or report and submits investigation forms within 5 days of closure or timeframe agreed upon in consultation with PHNS (p. C6).

  • 6.

    Follows up on referrals as reported by client if more than one contact is needed (p. C5).

TOTALS COMMENTS:

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

N/A

N/A

MET

MET

NOT MET

MET

NOT MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

April-Sept

Year

COMMENTS

F 15

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