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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

__________________________

POPULATION DIAGNOSIS AND PRIORITIES

1. Documentation indicates medical diagnosis (p. C50).

N/A

N/A

MET

NOT MET

MET

MET

NOT MET

NOT MET

N/A

2. Priority of follow up documented (p. C50) 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. C50).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

April- Sept

Year

COMMENTS

F 54

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