PWS Attachment 20 MEDCOM Form 829 Initial Entry Tuberculosis Risk Assessment Tool.pdf

Please wait...

If this message is not eventually replaced by the proper contents of the document, your PDF viewer may not be able to display this type of document.

You can upgrade to the latest version of Adobe Reader for Windows®, Mac, or Linux® by visiting http://www.adobe.com/go/reader_download.

For more assistance with Adobe Reader visit http://www.adobe.com/go/acrreader.

Windows is either a registered trademark or a trademark of Microsoft Corporation in the United States and/or other countries. Mac is a trademark of Apple Inc., registered in the United States and other countries. Linux is the registered trademark of Linus Torvalds in the U.S. and other countries.

INITIAL ENTRY TUBERCULOSIS (TB) RISK ASSESSMENT TOOL

For use of this form see, MEDCOM Reg 40-64, the proponent agency is MCPO-SA INITIAL ENTRY Tuberculosis (TB) Risk Assessment Tool

REVIEWER INSTRUCTION

1.

Have you ever had face-to-face contact with someone who was sick with tuberculosis (TB)?

Yes No

2. Were you born outside the United States? If yes, list the country:

Yes No 3.

Did you ever live with a family member who was born outside the United States? If yes, list the country:

Yes No

4. Have you ever had a positive TB test, prior diagnosis of TB, or prior treatment for TB?

Yes No If "NO" answers = low risk > STOP.

If all "NO" responses, then do NOT test.

Any "YES" answers = increase risk > Go to question #5

5. Do you have any of the following symptoms of tuberculosis?:

cough > 2 weeks, fever > 2 weeks, drenching night sweats, or unplanned weight loss.

Yes No If "YES" then refer immediately to provider for evaluation of TB disease.

If "YES" > STOP.

If "NO" > Go to question #6.

6.

Do you have documentation of previous TB treatment with you today?

Yes No

STOP.

If "YES" > Do NOT test.

Reviewer comments:

Document exemption in

MEDPROS.

If "NO" > Test for TB.

Note: If "Yes" response only to questions 2 or 3 above, testing is only required if the country is listed on the reverse side.

PATIENT'S IDENTIFICATION (For typed or written entries give:

Name- last, first, middle; DOB; SSN; date; hospital or medical facility)

REVIEWER NAME

REVIEWER SIGNATURE

MEDCOM FORM 829, FEB 2014

MC LC v1.01ES Record Name The following countries, if documented on the TB Risk Assessment Tool, indicate need for patient to be tested:

Senegal Afghanistan Egypt Malaysia Serbia Algeria El Salvador Maldives Angola Equatorial Guinea Serbia & Montenegro Mali Anguilla Eritrea Seychelles Marshall Islands Argentina Estonia Sierra Leone Mauritania Armenia Ethiopia Singapore Mauritius Azerbaijan Fiji Solomon Islands Micronesia - Fed States Bahrain French Polynesia Somalia Moldova Bangladesh Gabon South Africa Mongolia Belarus Gambia Sri Lanka Montenegro Belize Georgia Sudan Montserrat Benin Ghana Suriname Morocco Bhutan Guam Swaziland Mozambique Bolivia Guatemala Syrian Arab Republic Myanmar Bosnia and Herzegovina Guinea Tajikistan N. Mariana Islands Botswana Guinea-Bissau Tanzania Namibia Brazil Guyana Thailand Nauru British Virgin Islands Haiti Timor-Leste Nepal Brunei Darussalam Honduras Togo New Caledonia Bulgaria India Tonga Nicaragua Burkina Faso Indonesia Trinidad and Tobago Niger Burundi Iran Tunisia Nigeria Cambodia Iraq Turkey Pakistan Cameroon Japan Turkmenistan Palau Cape Verde Kazakhstan Turks and Caicos Islands Panama Central African Republic Kenya Tuvalu Papua New Guinea Chad Kiribati Uganda Paraguay China Korea - DR Ukraine Peru China, Hong Kong SAR Korea - Rep of Uruguay Philippines China, Macao SAR Kuwait Uzbekistan Poland Colombia Kyrgyzstan Vanuatu Portugal Comoros Lao PDR Venezuela Qatar Congo Latvia Viet Nam Romania Congo - DR Lesotho Wallis and Futuna Islands Russian Federation Cook Islands Liberia West Bank and Gaza Strip Rwanda Cote d'Ivoire Libya Yemen Saint Vincent & Grenadines Croatia Lithuania Zambia Samoa Djibouti Macedonia Zimbabwe Sao Tome and Principe Dominican Republic Madagascar Saudi Arabia Ecuador Malawi

MEDCOM FORM 829, FEB 2014

11.0.0.20130303.1.892433.887364