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Sexually Transmitted Disease Standard of Practice Evaluation Form

PHN

__________________________

Circle appropriate period

Oct-March

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. C35).

  • 2.

    Documents client understands the disease process and prevention of transmission

    • (p.

      C35).

  • 3.

    Determines and documents the effectiveness of interventions (p. C35).

      • Verifies with appropriate medical provider or per client’s self report that treatment was obtained and taken.

  • 4.

    Initiates action for non-adherent client/contacts (p. C35).

  • 5.

    Follow up with non-adherent client/contacts (p. C35).

  • 6.

    Dispositions and closes case in Casewatch® within 14 days of receipt of referral or within timeframe agreed upon with PHNS (p. C35).

  • 7.

    Follows up on referrals as reported by client, if more than one client contact is needed (p. C34).

TOTALS

© 2007 LAC DPH-Public Health Nursing

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

NOT

NOT

NOT

MET

MET

N/A

MET

MET

N/A

MET

MET

N/A

April- Sept

Year

COMMENTS

F 40

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