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STANDARD ELEMENTS

RECORD #

RECORD #

(1)

(2)

Newborn Screening Standard of Practice Evaluation Form

Circle appropriate period

Oct-March

PLANNING

Documents client specific plan that is selected from the PHN Practice Manual (pp. C28-C29).

PHN

__________________________

MET

N/A

NOT MET

N/A

MET

NOT MET

COMMENTS:

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual

    • (p.

      C29).

  • 2.

    Documents health teaching/counseling

    • (p.

      C29).

  • 3.

    Follows up on referrals as reported by caregiver if more than one contact is needed

    • (p.

      C 29).

COMMENTS:

MET

NOT MET

N/A

MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

April- Sept

COMMENTS

Year

F 34

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