Tuberculosis Patient Management Plan Form

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TUBERCULOSIS PATIENT MANAGEMENT PLAN
FAX in anticipation of discharge:
1.
Health Department for the client’s town of residence
2.
State of CT, TB Control Program, 860-509-7743
CLIENT NAME_____________________________________ DOB _____________ RECORD NO. ____________
ADDRESS_________________________________ PHONE __________ ADMIT DATE ______ D/C DATE _____
CLIENT’S EMERGENCY CONTACT__________________________________________ PHONE_____________
ADDRESS__________________________________________________________________________________
The following TB management plan for the client named above has been discussed with the undersigned care
providers and client. The care providers agree that this plan is consistent with public health regulation 19a-504c and
public act 95-138, requiring a written discharge plan and that plan provide the best medical and public health care
available for this client.
This case was reported to the local and state health departments by __________________________ Date_______
Follow-up TB care physician______________________________ Phone __________ Appointment date ________
Drugs and Dosages Prescribed:
INH __________
RIF __________
PZA __________
EMB ________
SM __________
B-6 __________
Other ________
Other _________
To be ingested:
DAILY
2x WEEKLY
3x WEEKLY
OTHER ____________
(NOTE: Generally, all patients should be on 4 anti-TB drugs until susceptibility results are available.)
Supervision:
Directly observed (DOT) Current ATS standard of care
self-administered
Other ________
DOT Worker(s) will be: ____________________________________ (weekdays) Phone _____________________
___________________________________ (weekends) Phone _____________________
Site(s) and time(s) for Directly Observed Therapy (DOT):
at: ____________________________________________________________ time: _____________ on weekdays
if necessary, at: _________________________________________________ time: _____________ on weekends
Local/State Public Health Case Manager is ________________________________ Phone: __________________
TB specific education and counseling provided by ____________________________________ Date___________
Obstacles to therapy adherence identified to date:
None
Homelessness
Physical limitation
Substance abuse ___________________
Cognitive limitation
Mental status
Other _____________________________
Proposed interventions for obstacles identified above: ________________________________________________
Referral(s) were/will be made on ___________ (date):
Agency/Person: _________________________________________________ Phone _________________
Agency/Person: _________________________________________________ Phone _________________
The following individuals have been notified and approve of above treatment plan:
Physician:
_______________________________________________________________ Date: ____________
Client:
_______________________________________________________________ Date: ____________
Local Health Director or Designee: _______________________________________________ Date: ____________
04/04/11

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