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STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Tuberculosis (TB) Cases and Suspects Standard of Practice Evaluation Form

Circle appropriate period

Oct-March

POPULATION DIAGNOSIS AND PRIORITIES

PHN

__________________________

N/A

N/A

MET

NOT MET

N/A

MET

NOT MET

MET

NOT MET

  • 1.

    Documentation indicates medical diagnosis (p. C41).

  • 2.

    Priority of follow up is documented

    • (p.

      C41) as outlined in the PHN Practice Manual (p. D7) or as determined in consultation with the PHNS.

COMMENTS:

OUTCOMES IDENTIFICATION

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

Documents health needs/goals for specific need(s) identified (p. C41).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

April- Sept

Year

COMMENTS

F 48

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