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Sexually Transmitted Disease Standard of Practice Evaluation Form

PHN

__________________________

Circle appropriate period

Oct-March

STANDARD ELEMENTS

POPULATION DIAGNOSIS AND PRIORITIES

  • 1.

    Documentation indicates medical diagnosis (p. C31).

  • 2.

    Priority of follow up documented

    • (p.

      C31) as outlined in the PHN Practice Manual (p. D5) or as determined in consultation with the PHNS.

COMMENTS:

OUTCOMES IDENTIFICATION

Documents health needs/goals for specific need(s) identified (p. C32).

COMMENTS:

PLANNING

Documents client’s specific plan that is selected from the PHN Practice Manual (pp. C32-C34).

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

N/A

N/A

NOT MET

MET

NOT MET

MET

N/A

MET

NOT MET

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

April- Sept

Year

COMMENTS

F 38

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