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STANDARD ELEMENTS

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Tuberculosis (TB) Contact Follow-up Standard of Practice Evaluation Form: Individual

Circle appropriate period

Oct-March

PHN

__________________________

ASSESSMENT

  • 1.

    Documentation reflects that referral was reviewed as indicated by:

    • Date/Time/Signature on referral when received from PHNS

      • (p.

        C49).

  • 2.

    Analyzes the report per PHN Practice Manual (p. C49) as demonstrated by the completeness or incompleteness of the data.

    • Indicates that all data was complete or follows up on missing data, if needed.

3. PHN Assessment was completed or if not, why? (p. C50).

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

April- Sept

Year

COMMENTS

F 53

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