TB Chart Audit Tool May 22, 2013
TB Case or Suspected Case Chart Audit Tool
|LOCAL HEALTH DEPT: |PATIENT INITIALS: |
|REVIEWER: |DATE OF REVIEW: |
|The following criteria are completed and documented |Yes |No |N/A |Comments |
|A. Medical Evaluation & Diagnosis |
|Complete medical history (reason for evaluation, s/s, list of medications, medical conditions other than| | | | |
|TB.) | | | | |
|Complete social history (risk factors for TB, REAL-D, place of birth, housing status, psychiatric, drug | | | | |
|or alcohol use, other.) | | | | |
|TST date(s) and result(s) recorded in “mm” and positive/negative OR IGRA results recorded OR is a | | | | |
|laboratory confirmed case before reported to LPHA. | | | | |
|Chest radiography date(s) and result(s) (PA and Lateral for ages ≤5.) | | | | |
|Bacteriology (smears, cultures, susceptibilities) and/or pathology report date(s)/results. | | | | |
|HIV test offered, or if HIV test done by another provider, documentation of previous + result within six| | | | |
|months of evaluation. New testing is preferred. | | | | |
|If HIV+, CD4 count documented in medical record. | | | | |
|Patient education (test results, adverse reactions, symptoms of disease, consequences of non-adherence).| | | | |
|Probable TB cases reclassified within 60 days of initial report. | | | | |
|(Class 5) | | | | |
|B. Infection Control |
|Airborne infection isolation initiated, if infectious. | | | | |
|Patient education on importance of isolation and proper use of masks. | | | | |
|Isolation discontinued appropriately after three consecutive negative smears (8–24 hours apart, with at | | | | |
|least one sample collected in early morning) and at minimum 5 days of DOT. | | | | |
|C. Treatment |
|Signed informed consent for TB Medication written in patient’s preferred language or written in English | | | | |
|with evidence that interpretation was provided by a trained interpreter. | | | | |
|Appropriate four-drug therapy was started (date, dosage appropriate for weight) or documentation and | | | | |
|consultation noted if any drug withheld. | | | | |
|Treatment regimen adjusted appropriately when susceptibilities are known. | | | | |
|DOT documented and recorded appropriately (Mon-Fri, weekends not included). | | | | |
|Treatment in continuation phase is three times a week or daily DOT | | | | |
|Consultation with treating provider or OHA if drug resistance is identified. | | | | |
|Consultation or physician evaluation of patient after two months of therapy, if not responding | | | | |
|clinically or still culture positive at two months. | | | | |
|Length of therapy extended to at least nine months, if chest x-ray is cavitary and culture is positive | | | | |
|at two months. | | | | |
|Appropriate action is taken if DOT or clinic appointments are missed, up to and including use of legal | | | | |
|order according to policy. | | | | |
|If patient no longer on treatment, case record was appropriately closed as completion of adequate | | | | |
|therapy, non-TB, deceased or lost. | | | | |
|If patient case was closed as completion of adequate therapy, therapy was completed within 12 months | | | | |
|unless otherwise clinically indicated. | | | | |
|If patient moved out of jurisdiction, appropriate referrals were made. | | | | |
|D. Monitoring |
|Appropriate baseline blood studies (AST, bilirubin, alkaline phosphatase, serum creatinine, platelet, | | | | |
|hepatitis B and C, and CD4 count if HIV+) were completed. | | | | |
|If ethambutol (EMB) is prescribed, visual acuity (Snellen chart) and color discrimination (Ishihara | | | | |
|plates) dates/results at baseline and monthly until ethambutol discontinued. | | | | |
|Sputum was collected monthly until culture conversion documented for drug susceptible, pulmonary or | | | | |
|laryngeal TB disease. | | | | |
|Monthly clinic/home visit by nurse case manager to assess for therapeutic response, patient needs and TB| | | | |
|medication adverse effects. | | | | |
|Chest radiography at start of therapy, and completion of treatment at minimum. | | | | |
|Appropriate referrals for medical and social services initiated and results of referrals documented in | | | | |
|the medical record, on referral form or in a progress note. | | | | |
|E. Contact Investigation |
|Case or appropriate proxy interviewed within three days of initial notification or report to health | | | | |
|department. | | | | |
|A visit to the place where the case person with TB disease or probable TB disease lives is documented in| | | | |
|the progress notes. | | | | |
|Contact investigation is initiated within 72 hours of confirming the case has TB disease. | | | | |
|All contacts ................
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