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

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. C54).

  • 2.

    Documents client understands the disease and transmission process

    • (p.

      C54).

  • 3.

    Initiates action for non-adherent client

    • (p.

      C54).

  • 4.

    Follows up with non-adherent client

    • (p.

      C54).

  • 5.

    Completes and submits H289 registration per PHN Practice Manual (pp. C54-C55).

  • 6.

    Ensure that H304 Preventative Treatment Closure is dispositioned and submitted if indicated (p. C55).

  • 7.

    Follows-up on referrals as reported by client (p. C53).

TOTALS COMMENTS:

© 2007 LAC DPH-Public Health Nursing

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

N/A

MET

NOT MET

MET

N/A

NOT MET

N/A

MET

NOT MET

April- Sept

Year

COMMENTS

F 56

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