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

PHN

__________________________

Circle appropriate period

Oct-March

STANDARD ELEMENTS

EVALUATION

  • 1.

    Documentation reflects consideration of facility needs in determining interventions and/or on- going revisions of plan of care (p. C12).

  • 2.

    Initiates action for non-adherent facility (p. C12).

  • 3.

    Follows up on non-adherent facility (p. C12).

  • 4.

    Completes and submits interim reports as needed until case is closed (p. C13).

  • 5.

    Completes and submits investigation forms within 10 days of closure or timeframe agreed upon in consultation with PHNS (p. C13).

  • 6.

    Completes Consumer/Community Services module in NPMS, and files hard copy in medical record (p. C13).

  • 7.

    Follows up on referrals as reported by facility administrator. (p. C12).

TOTALS

COMMENTS:

MET

RECORD #

RECORD #

(1)

(2)

NOT MET

N/A

MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

April- Sept

COMMENTS

Year

F 20

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