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

PHN__________________________

Circle appropriate period

Oct-March

April- Sept

Reviewing Supervisor (name)

Record #1

Calculation of Percentage (%)

(Signature)____________________________________ Date

18 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

Reviewing Supervisor (name)

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

Record #2

Calculation of Percentage (%)

(Signature)____________________________________ Date

18 possible Standard Elements MINUS (-) not applicable (N/A) Elements = Denominator

  • #

    of MET Elements

Total # of Standard Elements (Denominator)

=

Comments:

Compute average compliance for rating period: Total of percentages =______% (Record percentage on Attachment B under ACD Outbreak HCF)

  • #

    of records

© 2007 LAC DPH-Public Health Nursing

Year

%

%

F 21

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