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

PHN

__________________________

Circle appropriate period

Oct-March

April- Sept

STANDARD ELEMENTS

EVALUATION

  • 1.

    Documentation reflects consideration of facility needs in determining interventions and/or on-going revisions of the plan of care (p. C19).

  • 2.

    Initiates action for non-adherent facility

    • (p.

      C19).

  • 3.

    Follows up on non-adherent facility

    • (p.

      C19).

  • 4.

    Completes and submits interim reports as needed until case is closed (p. C19).

  • 5.

    Completes and submits investigation forms within 10 days of closure or timeframe agreed upon in consultation with PHNS (p. C19).

  • 6.

    Completes Consumer/Community Services module in NPMS, and files hard copy in medical record (p. C19).

  • 7.

    Follows up on referrals as reported by facility administrator (p. C18).

TOTALS COMMENTS:

© 2007 LAC DPH-Public Health Nursing

RECORD #

RECORD #

(1)

(2)

MET

NOT MET

N/A

MET

NOT MET

N/A

COMMENTS

Year

F 25

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