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STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Sexually Transmitted Disease Standard of Practice Evaluation Form

Circle appropriate period

Oct-March

PHN

__________________________

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual (p. C34).

  • 2.

    Documents health teaching/counseling

    • (p.

      C34).

  • 3.

    Interviews for contacts (p. C34).

  • 4.

    Refers client/contacts as needed

    • (p.

      C34).

  • 5.

    Conducts surveillance of client as indicated (p. C34). (Surveillance describes & monitors health events through ongoing & systematic collection, analysis, & interpretation of health data).

COMMENTS:

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 39

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