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Tuberculosis (TB) Source Case Finding in a Documented Converter Standard of Practice Evaluation Form

PHN

__________________________

STANDARD ELEMENTS

POPULATION DIAGNOSIS AND PRIORITIES

  • 1.

    Documentation indicates medical diagnosis (p. C56).

  • 2.

    Priority of follow up documented

    • (p.

      C56) as outlined in the PHN Practice Manual (p. D7) or as determined in consultation with the PHNS.

COMMENTS:

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

Circle appropriate period

Oct-March

April- Sept

Year

COMMENTS

MET

N/A

N/A

NOT MET

N/A

MET

NOT MET

MET

NOT MET

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. C57).

COMMENTS:

© 2007 LAC DPH-Public Health Nursing

F 59

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