Download Tuberculosis Record

Tuberculosis Record
Complete for client with suspect/active TB disease and/or TB infection
For questions please call: 505-827-2471/2473/2500
Please fax this form with client demographics, H&P, Radiology & Lab reports to 505-827-0163
ECHO ID#
2. Nurse Case Manager
1. Date:
Referred by:
5. Last name
3. BEHR/Medical Record #
6. First
11. Address
10. Phone(s)
16. Status
12. City
17. Race
White
Asian,
Suspect Active TB
Active TB
TB Infection
positive TST/ QFT/
T.Spot
18. Ethnicity & Sex
Hispanic
Non-Hispanic
Pacific Islander
Black
American
Indian
Other
NKDA
Allergy List:
_______________
_______________
_______________
_________
22. Occupation: HCW
Place of employment:
Sex
Male
Female
4. Hospitalized Yes
Where:
7. MI
8. DOB
13. State
19. Reason for Testing
Public Health
Symptoms/ diagnostic
Contact to TB case
Refugee Health Screen
Immigration
Work requirement
Rheumatology
Dialysis/ESRD
Other:
Specify:____________
Correctional Employee
migrant/seasonal worker
not employed
23. Diabetes
24. Substance Use
25. HIV Status
26. Lung
Disease
Yes
No
List DM Meds:
_____________
_____________
_____________
_____________
________
none
injection drug use
________________
other drug use
________________
alcohol use
Amount:_________
Date tested:
_________
negative
positive
none
pneumonia
COPD
other,
specify:
refused
retired
27.
GI/GU
none
CKD
Dialysis
Pregnancy
Due Date:
Date:
9. Age
14. ZIP
20. Residence
Private residence
Homeless
Shelter
Jail/prison
Long Term Care
Facility
Substance Abuse
Treatment center
School Setting
Other
Testing by Private Provider
No
not seeking employment
15. County
21. Country of birth
United States
Mexico, specify
State:
Other, specify
Date of entry to US
Travel History:
Bi-National
other occupation
unknown
28. Cancer/
Chemotherapy
29. Hepatitis
30.
Medications
none
cancer
immunosuppressive
therapy
other, Specify:
none
Hepatitis A
Hepatitis B
Hepatitis C
other liver
disease
_______________
_____________
none
steroids
TNF α blockers
See attached
list
tobacco use
CLINICAL STATUS
31. TB Treatment
32. Symptoms
None
TB Infection no treatment
TBI incomplete treatment
TBI completed treatment
Date:_________# months________
(Written documentation needed)
TB Disease Treatment
Date:_________# months________
(Written documentation needed)
none
cough >2-3 weeks
weight loss:________lb
hemoptysis
night sweats
fever
Specimen
IGRA/TST
36. TB Medications/Dosages
Smear
Result
(TST in mm)
No previous test (TST or IGRA)
Previous positive test: Date________________
History of BCG
lbs/kgs
35. Laboratory Diagnostics
Date
Date
34. Chest x-ray
CXR Date:
Normal
Abnormal
Infiltrates
Cavity
CT Scan:
other ______________
Current wt:
Current ht:
BMI:
Comments:
33. TB Test Results
NAAT/PCR
Culture
Isoniazid (INH)__________
Rifampin (RIF)__________
Rifapentine:_____________
Pyrazinamide (PZA)______
Ethambutol (EMB)________
Pyridoxine (B6)___________
Moxifloxacin
FAX radiology reports to TB
Program @ 505.827.0163
37. Meds
38. Contact to TB Case
Start date:
Relation to Case:_____________
Date of last contact:___________
Sputum Smear results of case:
positive
negative
Duration:
GENType:
Matches:
39. Stopped Therapy
40. Length on Therapy
Completed treatment
Stop date:
Refused
Active TB
Months on therapy
Moved
Doses given:
Adverse reaction:_______
Lost
Reported by:
Died
Provider decision to stop
Other
Date:
Nurse/Doctor evaluating patient:
Comments:
Facility/Phone:
Yes
No
41. Tuberculosis Classification
0 Not exposed, not infected
1 Exposed, not infected
2 LTBI
3 Active TB pulmonary extra
pulmonary
4 Inactive tuberculosis
5 TB suspect
6 NTM, specify
7 Unclassified
INSTRUCTIONS
1. The DOH assigned facility code for the public health office submitting the TB011
2. The name of the nurse that is responsible for the coordination of care of this patient. (Other nurse may complete related activities in the
absence of the RN case manager).
3. The medical record number assigned to the patient in NM DOHs billing and electronic medical record (BEHR) system.
4. Check if the patient was hospitalized or not, write where they were hospitalized if “yes”, and the dates of hospitalization.
5. Patient’s last name, if patient has two last names be sure to include both in the correct order.
6. Patient’s first, or given, name.
7. Patient’s middle initial.
8. Patients date of birth, in format dd/mm/yyyy
9. Patient’s age, accurately reflecting their date of birth.
10. Patient’s phone number, including area code.
11. Patient’s street address.
12. The city in which the patient resides.
13. The state in which the patient resides.
14. The zip code in which the patient resides.
15. The county in which the patient resides.
16. Patient’s TB status: check the box that best fits the patient’s current status in terms of TB diagnosis at the time the TB011 is submitted.
17. Check the patient’s “race”-always ask the patient, do not make assumptions about what you believe their race is.
18. Check the patient’s ethnicity- always ask the patient, do not make assumptions about what you believe their ethnicity is. Check if the
patient’s gender is male or female.
19. Check the reason the patient is being tested for TB, note the distinction between public health & private provider reasons for testing. For
private providers, the patient should come with TST/IGRA results, and CXR in hand to be evaluated for TB, and/or to start LTBI treatment.
20. Check the box that best describes the patient’s place of residence.
21. Check the box indicating the country the patient was born in. For Mexico, also ask the state they were born in (i.e. Chihuahua, Oaxaca,
Zacatecas, etc.) not the city. If they were born in a country other than the US or Mexico, please specify. If they recently traveled to a TB
endemic country, note the country in travel history. If the patient and/or their immediate family are binational, please also check this box.
22. Check the box that best describes the patient’s occupation, and document the place if they are employed at the time the TB011 is
submitted.
23. Check if the patient has been diagnosed with diabetes, and note any medication they are taking for diabetes if the answer is yes.
24. Check the box(s) that best describe substances the patient admits to using, if any.
25. Check the patient’s HIV test result for positive or negative; include the date the test was done. If test refused check the indicated box. All
TB disease and LTBI patients should be offered HIV testing.
26. Check if the patient has any other lung disease diagnose(s), specify the type if other.
28. Check if the patient has been diagnosed with cancer and/or are taking chemotherapy for cancer or other conditions.
29. Check if the patient has been diagnosed with Hepatitis. If the patient admits to injection drug use, they should be tested for hepatitis B
and C, with appropriate f/u depending on results.
30. Check the box that best responds to the patient’s current use of medications, allergies to medications, or other medication-related
information that could affect TB care.
31. Check the box that best describes the patient’s history of TB or LTBI treatment, include the date and months treated based on written
documentation of such treatment. Fax to TB program previous treatment documentation with TB Record. ( or scan into BEHR???)
32. Check all boxes for symptoms the patient had at the time the TB011 was submitted include the current weight, height and BMI.
33. Document the date(s) of any TST that was placed, or IGRA drawn, and the result. If TST documented, note the result in millimeters. If an
IGRA, note positive, negative, or indeterminate. Also check the boxes about previous testing, and history of BCG vaccine.
34. Note the date a chest x-ray (CXR) was done in relation to the patient’s referral to DOH (if applicable), note the date a DOH CXR was
done, and check the box that best indicates the CXR results. Be sure to fax any CXR reports related to this patient to the TB Program.
35. For any laboratory testing that was done for this patient related to TB, note the date it was done (dd/mm/yyyy), the specimen it was done
on (i.e. sputum, BAL, urine or any other source) the results of the acid fast bacilli (AFB) smear (i.e. negative, 1+, 2+, 3+, 4+), results of the
nucleic acid amplification (NAA) test if done, and culture results.
36. Check the box(s) indicating which TB medications the patient is being given and the dose on the line following the medication options. If
other than the standard regimen, use blank space to write other medications. Include current weight in pounds here as well.
37. Indicate the date medications were started, if they were not recommended or patient refused- these are only an option for LTBI patients,
and check the box to indicate the anticipated duration of treatment at the time the TB011 was submitted.
38. If the patient is a contact to an active TB case, note the cases relationship to the patient, the RVCT number (if known- otherwise the TB
Program will document), the active cases smear results, date the patient had last contact with the case, and/or other case exposure
information in the line provided.
39. Check the box that best describes the reason the patient stopped therapy. If other, please specify in the blank space.
40. Note the date that therapy was stopped, the number of months the patient completed, the number of doses given under directly observed
therapy (DOT), the name of the person that reported the information, and the date they noted length of therapy.
41. Check the box that best describes the TB classification for the patient being evaluated and reported.
COMMENTS: Please use this space for any comments you wish to report that do not fit in another section. Be as concise and clear as
possible.
NURSE/DOCTOR please include the name of the nurse or physician evaluating the patient
FACILITY PHONE: please be sure to include the phone number (with area code) to your health office.
EVALUATION DATE: please be sure to include the date that the patient was initially evaluated.