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STANDARD ELEMENTS

RECORD #

RECORD #

(1)

(2)

Year

COMMENTS

Acute Communicable Diseases Standard of Practice Evaluation Form: Outbreak in a Non-Healthcare Facility/Agency

Circle appropriate period

Oct-March

April- Sept

POPULATION DIAGNOSIS AND PRIORITIES

  • 1.

    Documentation indicates medical diagnosis

    • (p.

      C15).

PHN

__________________________

N/A

N/A

MET

NOT MET

MET

NOT MET

2. Priority of follow up is documented as outlined in the PHN Practice Manual (p. D1, D2) or as determined in consultation with the PHNS (p. C15).

COMMENTS:

OUTCOMES IDENTIFICATION

MET

NOT MET

N/A

MET

NOT MET

N/A

Documents health needs/goals for specific need(s) identified (p. C15).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

F 23

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