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Tuberculosis (TB) Cases and Suspects 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. 46).

  • 2.

    Documents client understands the disease process and prevention of transmission (p. C46).

  • 3.

    Initiates action for non-adherent client (p. C46).

  • 4.

    Follows up with non-adherent client (p. C46).

  • 5.

    Completes and submits H290 registration per PHN Practice Manual (p. C47).

  • 6.

    Completes and submits H290 confirmation per PHN Practice Manual (p. C47).

  • 7.

    Submits H513 closure per PHN Practice Manual (p. C47).

© 2007 LAC DPH-Public Health Nursing

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

April- Sept

Year

COMMENTS

F 50

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