TB-205_Toxicity_Assessment_02_2018v2.doc
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- Attached to
- Electronic Health Records
- Solicitation number
- 2024-280
- Issued by
- Collin County, Texas
About this file
The document is a clinical assessment form from the Texas Department of State Health Services for monitoring tuberculosis medication toxicity, specifically designed for Collin County. The form is a comprehensive medical screening tool that tracks potential adverse drug reactions for patients undergoing tuberculosis treatment, with detailed sections for monitoring symptoms, vision screening, hearing tests, and color discrimination. The assessment covers multiple medication types and requires healthcare providers to document patient responses to various potential side effects, including changes in vision, hearing, physical symptoms, and overall health status.
The form is closely aligned with an Electronic Health Records (EHR) contract opportunity for Collin County Health Care Services, which seeks an integrated cloud-based and app-based solution for patient health information management. The EHR system is designed to generate and maintain digital patient health records across different care delivery settings, with the capability of sharing information between healthcare providers. While the document does not specify pricing or funding details, it demonstrates a systematic approach to patient monitoring and electronic health record maintenance, suggesting a sophisticated and thorough healthcare documentation strategy for the county.
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Text version
Texas Department of State Health Services
Clinical Assessment for Tuberculosis Medication Toxicity NAME: __________________________________D.O.B.: _____ /_____ /_____ SS#: _____ /____ /______
Adverse Drug Reaction Assessment: Ask all the below questions to monitor for medication toxicity, noting that some symptoms may be more commonly associated with certain medications. Those with** are associated with second-line drugs; those with †are associated with Isoniazid/Rifapentine (3HP) but may also be present in other regimens. Document any [+], incl. potential pregnancy in women, in progress notes & notify physician. Results: [+]=Present; [-]=Denies; [NA]=Not Applicable
Date
Weight
Temperature
Blood Pressure
Pulse
Use of new prescription or over the counter drugs, ie. Tylenol, herbal or other supplements, etc?
Ask women about signs of pregnancy (FDLMP)
| Drug Issued |
| Mfg/Lot#/Exp |
| Route/ Frequency |
| Amount |
| Amount |
| Amount |
| Amount |
| Amount |
| Amount |
| Amount |
| Amount |
| Amount |
Do you have any of the following symptoms now or since your last clinic appointment?
Abdominal pain/diarrhea** †
Abnormal behavior**
Allergic reaction (specify)** †
Bruises, red/purple spots on skin†
Change in heart rate**
Change in urine output
Convulsions**
Dark urine (coffee colored) or change in color†
Ears ringing/fullness/hearing loss**- AK,CAP,KM, SM
Eye pain/irritation (redness, excessive tears)
Fever or chills†
Flu-like symptoms†
Headaches (chronic)
Increased gas/stomach cramps**
Jaundice (yellow skin/eyes) †
Joint pain/swelling (chronic) – PZA
Light colored stools†
Loss of appetite†
Malaise/fatigue
Memory Loss**
Mood changes/depression**
Musculoskeletal Pain†
Nausea/vomiting†
Numbness/tingling/pain, arms, legs†
Nervousness/Giddiness/Restlessness
Skin discoloration**
Skin rashes/itching†
Sleep problems**
Sores on lips or inside mouth†
Shortness of breath†
Teeter/Fall to Left or Right when standing (eyes closed)
Unusual bleeding (nose, gums, stool, urine, etc.) or easy bruising - RIF, RPT†
Vertigo/dizziness/fainting†
Visual problems/changes in vision*** - EMB, RBT
Weakness, tiredness†
Weave/Stagger when walking (normal gait)
Initials*/Title
Interpreter
Next Appt.
TB205- Clinical Assessment for TB Medication Toxicity- Revised 8/2017; Amended by Collin County 2/2018 (Continued on Reverse) Texas Department of State Health Services
Vision/Hearing Screening Form
NAME: __________________________________D.O.B.: _____ /_____ /_____ SS#: _____ /____ /______
| Ishihara Plate # |
| Normal Reading |
| Red/Green |
Deficiency
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| 1 |
| 12 |
| 12 |
| 2 |
| 8 |
| 3 |
| 3 |
| 5 |
| 2 |
| 4 |
| 29 |
| 70 |
| 5 |
| 74 |
| 21 |
| 6 |
| 7 |
| X |
| 7 |
| 45 |
| X |
| 8 |
| 2 |
| X |
| 9 |
| X |
| 2 |
| 10 |
| 16 |
| X |
| 11 |
| Traceable |
| X |
| Protan |
| Deutan |
| Strong |
| Mild |
| Strong |
| Mild |
| 12 |
| 35 |
| 5 |
| (3) 5 |
| 3 |
| 3 (5) |
| 13 |
| 96 |
| 6 |
| (9) 6 |
| 9 |
| 9 (6) |
| 14 |
| Can trace |
2 lines
| Purple |
| Purple (Red) |
| Red |
| Red (Purple) |
Results
Initials
Distance
Acuity Date
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Right Eye |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| Left Eye |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| Both Eyes |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
| 20/ |
Results
Initials
| Frequency |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Date |
| Ear |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
| R |
| L |
500 Hz
1000 Hz
2000 Hz
4000 Hz
Initials
TB205- Clinical Assessment for TB Medication Toxicity - Revised 8/2017; Amended by Collin County 2/2018
* From previous page: See Provider Signature Sheet
*** From previous page: Changes in Vision may include blind spots in field of vision, blurred vision, changes in peripheral vision Red/Green Color Discrimination:
The (X) mark indicates the plate cannot be read. Screen all 14 plates. Client must pass 10 of the first 11 plates for the test to be regarded as normal. Refer for evaluation if < 7 plates are read as normal.
Results: [ N ] = Normal [ A ] = Abnormal
Visual Acuity:
If initial screen was conducted with corrective lenses (glasses or contacts), follow-up screens must be done the same. A change of 1 or more lines from the initial screen in either one or both eyes must be reported to the physician immediately.
Results: [ P ] = Pass [ F ] = Fail [ U ] = Unscreenable Chart Used: [ ] Letter [ ] “E” [ ] Other, Specify:_______________
Corrective Lenses: [ ] = Yes [ ] = No
KDISII
Hearing Sweep Check:
When patient is taking amikacin, capreomycin, kanamycin, or streptomycin, for each of the four frequencies listed, record the lowest level in decibels (dB) at which the person responds. Record the findings for both the right and left ear. Refer to an appropriately licensed professional if any two of the four frequencies are recorded as greater than 25 dB in either ear or the same ear or if there is a change of decreased hearing level from baseline. Start with 40 dB, if heard decrease by 10 dB until no response is obtained or until 20 dB is reached. If 20 dB is heard, record as 20 dB. Once no response is obtained, increase the dB level by 5 until a response is obtained and recorded. If a response is not heard at 40 dB, record as 40+ dB.
Results: [ P ] = Pass [ R ] = Refer [ O ] = Observe Ear: [ R ] = Right [ L ] = Left
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