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PHN

__________________________

STANDARD ELEMENTS

EVALUATION

  • 1.

    Documentation reflects consideration of client’s needs in determining interventions and/or on-going revisions of the plan of care (p. C25).

  • 2.

    Documents client understands lead poisoning (p. C25).

  • 3.

    Initiates action for non-adherent client (p. C25).

  • 4.

    Follows up on non-adherent client

    • (p.

      C25).

  • 5.

    Completes and submits lead investigation forms as per PHN Practice Manual (pp. C25-C26).

6. Follows up on referrals as reported by client (p. C25).

TOTALS

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

Lead Standard of Practice Evaluation Form

Circle appropriate period

Oct-March

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

MET

MET

NOT MET

N/A

N/A

NOT MET

N/A

MET

NOT MET

April- Sept

Year

COMMENTS

F 30

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