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MET

NOT MET

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NOT MET

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STANDARD ELEMENTS

RECORD #

RECORD #

(1)

(2)

Year

PLANNING

Documents facility specific plan that is selected from the PHN Practice Manual (pp. C9-C11).

COMMENTS:

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual

    • (p.

      C12).

  • 2.

    Interviews for source (p. C12).

  • 3.

    Documents health teaching/counseling

    • (p.

      C12).

  • 4.

    Refers facility administrator or designee as needed (p. C12).

  • 5.

    Conducts surveillance of facility as indicated

    • (p.

      C12). (Surveillance describes and monitors health events through ongoing and systematic collection, analysis, and interpretation of health data).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

COMMENTS

F 19

April- Sept

Acute Communicable Disease Standard of Practice Evaluation Form: Outbreak in a Healthcare Facility

Circle appropriate period

Oct-March

PHN

__________________________

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