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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