Tuberculosis Treatment Plan Form (Page 2 of 2) in pdf

Tuberculosis Treatment Plan Form Page 2

Guidelines for how to complete and submit the mandatory TB

Treatment Plan

As of June 16, 2010, article 11 of the New York City Health Code requires all health care providers to

submit a written TB Treatment Plan to the New York City Department of Health & Mental

Hygiene(DOHMH) within one month of starting treatment for newly diagnosed TB patients.

General information and guidelines regarding TB treatment

Treating a patient with tuberculosis is an important public health responsibility. To ensure treatment

adherence and completion, each TB patient is assigned to a DOHMH case manager who follows up on the

patient’s progress throughout the treatment duration. Directly Observed Therapy (DOT) is the standard

care for TB and should be proposed to the patient at the time of TB treatment initiation. DOHMH TB case

management also includes offering HIV counseling to all patients regardless of apparent risk factors.

Additional information and guidelines about TB treatment and control are available at the DOHMH

website:

Instructions for completing the Tuberculosis Treatment Plan Form

Section A Patient information and Section B Provider contact information: These sections are

completed by a DOHMH staff. Providers complete Section C and D.

Section C Clinical information: Check drug susceptibility results for all drugs. If drug susceptibility

results are pending or specimen has not been submitted for testing, check the box that says “No Results”.

Write the name and susceptibility results for drugs not specified. Indicate whether HIV testing was

performed. If HIV testing was not done, state the reason. Write all medications (other than TB

medications) that the patient is currently taking.

Section D Treatment regimen: Provide the date treatment was started, the estimated date of completion

and length of treatment. Provide the name, dosage and duration in months for each of the prescribed

drugs. Add drugs not specified if needed. State how often the medications are taken (frequency of

treatment). State if the patient is receiving DOT. If yes, provide the name and telephone number of the

patient’s DOT provider. If the patient is not on DOT, state the reason.

The provider must sign the form, and submit it to the case manager or fax it to the number listed on the

top of the form.

If you have questions about completing this form please contact 311 and ask to speak to a physician at the

Bureau of Tuberculosis Control.

Tuberculosis Treatment Plan Form Page 2