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MET

MET

N/A

MET

MET

N/A

MET

MET

N/A

NOT

NOT

NOT

MET

MET

N/A

MET

MET

N/A

MET

MET

N/A

April- Sept

Year

COMMENTS

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual (p. C46).

  • 2.

    Initiates contact investigation

    • (p.

      C46).

  • 3.

    Documents health teaching/counseling (p. C46).

  • 4.

    Refers client as needed (p. C46).

  • 5.

    Conducts surveillance of client as indicated (p. C46). (Surveillance describes & monitors health events through ongoing & systematic collection, analysis, & interpretation of health data).

  • 6.

    Documents monthly home visit/ contact (p. C46).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

F 49

STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

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

Circle appropriate period

Oct-March

PLANNING

Documents client’s specific plan that is selected from the PHN Practice Manual (pp. C41-C45). COMMENTS:

NOT

NOT

NOT

PHN

__________________________

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