HomeMy WebLinkAbouttuberculosis-discharge-treatment-plan-gotch-adaALAMEDA COUNTY PUBLIC HEALTH DEPARTMENT
TUBERCULOSIS DISCHARGE TREATMENT PLAN
Prior to anticipated discharge… Complete this form in entirety and fax to Alameda County TB Control Program: 510-273-3916
Discharge Date ☐ HOME ☐ SKILLED NURSING FACILITY ☐ SHELTER
☐ JAIL/PRISON ☐OTHER (SPECIFY _________________________)
Discharge Address: STREET CITY
ZIP CODE COUNTY PHONE NUMBER
Name of Medical Provider After Discharge
PAGER NUMBER PHONE NUMBER FAX NUMBER
Meds to last until appointment?
☐ YES ☐ NO
Follow Up Appointment
Date: Time: ☐ AM/☐ PM
SPECIAL INSTRUCTIONS
PART II: DISCHARGE MEDICATIONS / TREATMENT PLAN (Complete upon discharge)
CURRENT BACTERIOLOGY: Submit Current Reports DISCHARGE MEDICATIONS Weight:
DATE
(Month/Day/Year)
MEDICATION MGMS +/- +/- PDG
ISONIAZID
RIFAMPIN
PYRAZINAMIDE
ETHAMBUTOL
B6
OTHER
OTHER
OTHER
Current CXR Report
Date: ___________ ☐ Stable ☐ Improved ☐ Worse
Describe: _______________________________________________
_________________________________________________________
☐ Yes ☐ No
DOT To Occur Where? ☐ Clinic/MD ☐Home ☐ Worksite
☐ Other: __________________________________________
PHN Assessment
Received? ☐ Yes ☐ No
Reviewed? ☐ Yes ☐ No
☐ YES ☐ NO Problems Identified: ______________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Actions Required Prior to Discharge: ____________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Authorized By ________________________________________________________________ Date ________________________________
Alameda County Public Health Department
Tuberculosis Control Program
Tuberculosis Discharge Treatment Plan
Discharge of a Suspected or Confirmed Tuberculosis Patient
As of January 1, 1994, California State Health and Safety Codes mandate that patients suspected of
or confirmed as having TB may not be discharged or transferred without prior Health Department
approval. To facilitate timely and appropriate discharge, the provider should notify the Health
Department 1-2 days prior to anticipated discharge date to review the discharge criteria. (See below.)
Tuberculosis Control Program (TBC) Response Plan
For Weekday Discharge – Non Holiday: Monday to Friday 8:30 – 4:30pm
Upon receipt of a completed discharge request form, TB Control staff will provide a response within
24 hours. To expedite your request, please include all laboratory and/or radiology reports.
TBC staff will review the request and notify the submitter of approval, or will inform the submitter if
additional information or action is required prior to discharge approval. If a home evaluation is
needed to determine if the environment is suitable for discharge, the TBC staff will make a home visit
within (1) working day of notification.
Holiday and Weekend Discharge
If you anticipate a discharge on a weekend or holiday, please contact the TB Control Program
immediately.
In all instances, an accurately completed Discharge/Transfer Treatment Plan must be
submitted at least 24 hours prior to consideration for approval for discharge or transfer. If
these criteria cannot be satisfied, discharge cannot be approved and the patient MUST
be held until the next business day for appropriate arrangements to be made.
FAX NUMBER: (510) 273-3916
TB Medical Consultation: (510) 667-3054
Main TB Control Program: (510) 667-3096