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

PHN

__________________________

Circle appropriate period

Oct-March

April- Sept

Year

STANDARD ELEMENTS

PLANNING

RECORD #

RECORD #

RECORD #

(1)

(2)

(3)

MET

N/A

N/A

NOT MET

N/A

MET

NOT MET

MET

NOT MET

COMMENTS

Documents client specific plan that is selected from the PHN Practice Manual (pp. C57-C59).

COMMENTS:

IMPLEMENTATION

  • 1.

    Completes and documents disease and health event investigation per PHN Practice Manual (p. C59).

  • 2.

    Initiates SCF (p. C59).

  • 3.

    Documents health teaching/ counseling (p. C59).

  • 4.

    Refers client as needed (p. C59).

COMMENTS:

MET

NOT MET

N/A

MET

NOT MET

N/A

MET

NOT MET

N/A

© 2007 LAC DPH-Public Health Nursing

F 60

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