Completing the TB Follow-up Worksheet

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Completing the TB Follow-up Worksheet. Worksheet Objectives. The TB Follow-up Worksheet is designed to collect information on immigrants and refugees who have migrated to the US. They were classified overseas during the required medical examination process with a TB condition. - PowerPoint PPT Presentation

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  • Completing theTB Follow-up WorksheetIndiana State Department of HealthFebruary 2009

    Indiana State Department of Health

  • Worksheet ObjectivesThe TB Follow-up Worksheet is designed tocollect information on immigrants and refugees who have migrated to the US.They were classified overseas during the required medical examination process with a TB condition. Follow-up evaluation in the US was recommended.

    The TB Follow-up Worksheet is generated from the CDCs Electronic Disease Notification(EDN) system by ISDH.

    ISDH sends the overseas medical information and TB Follow-up Worksheet to the Local Health Department (the county of the immigrants/refugees [I/R] residence).

    The Local Health Department submits the completed TB Follow-up Worksheet to ISDH within 30 days if possible.

    Information from the TB Follow-up Worksheet is entered into the EDN system by ISDH and then transferred electronically to CDC.

    Indiana State Department of Health

    Indiana State Department of Health

  • The TB Follow-up WorksheetPage 1Indiana State Department of Health

    Indiana State Department of Health

  • The TB Follow-up WorksheetPage 2Indiana State Department of Health

    Indiana State Department of Health

  • Demographic InformationThis section is pre-populated by the EDN system. It includes the I/Rs demographic information.

    If this section is blank, enter the Name, Alien # and DOB from the overseas medical forms. That is sufficient.Note: Alien # is an A followed by 8 or 9 digits.

    Page 1Indiana State Department of Health

    Indiana State Department of Health

  • Jurisdictional InformationThis section is also pre-populated by EDN.It provides jurisdictional information based on the I/Rs U.S. address.

    If this section is blank, no worries. Leave it blank.

    Page 1Indiana State Department of Health

    Indiana State Department of Health

  • U.S. EvaluationThis section is for data entry of the medical evaluation performed in the U.S.

    C1 Enter the date of the initial medical visit

    C2a Check the appropriate box (example of unknown pt reports previous positive but has no documentation)

    C2b If C2a yes, enter the date the TST was placed.Please write the date the TST was read next to the placement date.

    C2c If C2a yes, write the mm size of the induration, ex 0mm

    C2d If C2a yes, check the appropriate box based on induration size and risk factors

    C2e If client has documentation of a previous positive TST, check box and leave C2a-C2d blank

    C3a Check the appropriate box

    C3b If C3a yes, enter the date of the blood draw for the QFT

    C3c If C3a yes, check the appropriate box

    NOTE: If there is no documentation of a previous positive TST, use the QFT for the TB screening if possible. (QFT not approved for use if

  • U.S. Review of Overseas CXRPage 1C4 Check the appropriate boxNOTE: C4 is only yes if a clinician in the US reviewed the film/disc brought by the I/R from overseas. This information is not from the overseas medical forms.

    C5 If C4 yes, check the appropriate box

    C6 If C4 yes & C5 Abnormal, check the appropriate boxNOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line.Indiana State Department of Health

    Indiana State Department of Health

  • Domestic CXRPage 1C7 Check the appropriate box

    C8 If C7 yes, enter the date of the US Chest X-Ray

    C9 If C7 yes, check the appropriate box

    C10 If C7 yes & C9 Abnormal, check the appropriate boxNOTE: If abnormality is other than what is listed in C10, check other and write the abnormality on the line.Indiana State Department of Health

    Indiana State Department of Health

  • ComparisonPage 1C11 - If C4 and C7 both yes, check the appropriate box.Indiana State Department of Health

    Indiana State Department of Health

  • U.S. Microscopy/BacteriologyNOTE: In case of more than three sputums, record results of additional test(s) in Comments NOTE: If additional tests other than the above were used, include them with corresponding results in Comments (Ex 3 sputums are documented in C12, but there is also a bronch wash result to record). Page 1C12If no specimen (ex - sputums, bronch wash, etc), check box before Specimen not collected in US

    If specimen collected, complete Lines 1-2-3 (one line for each specimen)Specimen Source write source (ex sputum)Date write MM/DD/YYYY source was collectedAFB Smear Result check appropriate boxCulture Result check appropriate box (NTM=non tuberculous mycobacteria)Drug Resistance(DR) check appropriate boxNOTE: Only check a box under DR if MTB Complex checked under Culture Result. Otherwise leave blank.NOTE: Ideally collect 3 sputums at least 8 hours apart with one collected first thing in AMIndiana State Department of Health

    Indiana State Department of Health

  • Review of Overseas Treatment Page 2You will find this information on the overseas medical forms.

    This section refers to treatment overseas for TB Disease (Active TB).NOTE: If the I/R was treated for TB infection (LTBI) overseas, please record this information in Comments

    C13 Check the appropriate box

    C14 Check the appropriate box (if no) or boxes (if yes)

    C15 Check the appropriate box

    C16 Check the appropriate box

    C17 - Check Yes if the U.S. medical evaluation raises concerns about inadequate or inappropriate drug regimen, drug doses, or treatment length for overseas treatment.NOTE: If C17 yes, record concerns in Comments

    Indiana State Department of Health

    Indiana State Department of Health

  • DispositionThis section is for entry of information following the completion of the I/R US medical evaluation.

    D1 Enter the date the evaluation was completed.

    D2 Check appropriate boxIf Completed... check appropriate box and continue with sections D3 and E.

    If Initiated... check appropriate boxSubmit to ISDH nowNOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up.If reason is other than what is listed, check other and write the reason on the line.

    If Did Not Initiate... check appropriate boxSubmit to ISDH nowNOTE: If patient moved, but you do not have a forwarding address, check Lost to Follow-up.If reason is other than what is listed, check other and write the reason on the line.

    D3 Check appropriate boxNOTE: If Class 3, check appropriate box

    D4 - Leave blank

    D5 Leave blankPage 2Indiana State Department of Health

    Indiana State Department of Health

  • U.S. TreatmentThis section is for entry of information regarding tuberculosis treatment provided to I/R in the US

    E1 Check appropriate boxIf No Treatment submit to ISDH now

    E2 If E1 is Active Disease or LTBI, write MM/DD/YYYY that I/R started treatment.If treatment started submit to ISDH nowWrite estimated date of completion in Comments

    E3 Check appropriate boxIf no, re-submit to ISDH now

    E4 If E3 yes, write MM/DD/YYYY that I/R finished treatment.Re-submit to ISDH nowPage 2Indiana State Department of Health

    Indiana State Department of Health

  • CommentsF - Enter comments as desired.Page 2Indiana State Department of Health

    Indiana State Department of Health

  • Physician SignaturePage 2G The worksheet data are sent to CDC electronically; therefore, the physicians signature is not required. Please write the Physicians name who did the evaluation.Indiana State Department of Health

    Indiana State Department of Health

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