HomeMy WebLinkAbouttuberculosis-medication-order-for-dot-adaTuberculosis Control
Amit Chitnis, MD, MPH, TB Controller
1100 San Leandro Blvd., 3rd Floor I San Leandro, CA 94577
Main Line (510) 667-3096 I Fax (510) 273-3916
TUBERCULOSIS MEDICATION ORDER FOR DIRECTLY OBSERVED THERAPY (DOT)
DOT is the observation of a person taking his/her prescribed medication for the treatment of tuberculosis
(TB) disease or TB infection. Public Health guidelines recommend DOT as standard treatment for TB
disease. DOT can be done in-person or with the use of mobile video technologies.
Client’s Name: ___________________________________ D.O.B: ____________________________________
Medical Record No: _______________________________ Allergies: _________________________________
Public Health Nurse: ______________________________ Telephone: _______________________________
Date for DOT to begin: _____________________________ Weight (kg) : _____________________________
PANSENSITIVE
☐Discontinue Ethambutol when DST result received
☐Discontinue Pyrazinamide after 8 weeks dosing and/or 40 DOT doses
Comments: ______________________________________________________________________________________
_________________________________________________________________________________________________
Provider Signature: ________________________________ Date: ___________________________________
Print Name: _______________________________________ Facility: _________________________________
Phone No: ________________________________________ Fax No: _________________________________