INMATE NAME
ID #
DOB

TB/LTBI Clinic Flow Sheet for Correctional Facilities

Name of person completing this form: Title: ______

Name of Health Department Staff Assist: Title: ______

Inmate AKA / AKA DOB
INMATE ADDRESS / CITY/STATE/ZIP
EMERGENCY CONTACT NAME / PHONE

Record Search Information

SENT TO / DATE / FAX # / CONFIRMED TX
PREVIOUS TX / YEAR / WHERE
TST ADMIN / o Yes o No / DATE / READ DATE
CHEST X-RAY / o Normal o Abnormal / DATE / CLASS

Treatment

NO MEDICATIONS ORDERED MEDICATIONS ORDERED Start Date ______
INH / MG / DAILY X / MONTHS / DOSES
B6 / MG / DAILY X / MONTHS / DOSES
EMB / MG / DAILY X / MONTHS / DOSES
Rifampin / MG / DAILY X / MONTHS / DOSES
Rifamate / MG / DAILY X / MONTHS / DOSES
Other Medications (Please List) / ______

Labs Ordered/Sputums/Education

LABS ORDERED / CMP / CBC / HEPATITIS SCREEN / URIC ACID / OTHER
HIV / LFTs / MONTHLY Ñ / MONTHS
SPUTUM
SAMPLES / #1 COLLECTED – DATE / #2 COLLECTED – DATE / #3 COLLECTED – DATE
#1 RESULTS / #2 RESULTS / #3 RESULTS ______
EDUCATION PROVIDED / MEDICATION AUTHORIZATION SIGNED

Clinic Visits

BASELINE / Month 1 / Month 2 / Month 3 / Month 4 / Month 5 / Month 6 / Month 7 / Month 8 / Month 9
MEDICATIONS / ALL MEDICATIONS MUST BE BY DIRECTLY OBSERVED - SWALLOWING (DOT)
# DOSE
INH
B6
EMB
RIF
ASSESSMENT / B/P
PULSE
TEMP
URINE
SKIN
ABDOMEN
COUGH
NIGHT SWEATS
RASH
NEUROPATHY
OTHER (describe)
VISION
COLOR
HEARING
LABS / SPUTUM
WBC
Hgb
PLATELETS
AST
ALT
URIC ACID
HIV
HEPATITIS A
HEPATITIS B
HEPATITIS C
Clinician’s Initials
DATE TREATMENT COMPLETED / NUMBER OF DOSES / RELEASE PLAN INITIATED / Yes No
TREATMENT NOT COMPLETED – REASON / Refuses Medication / Other
DATE RELEASED FROM FACILITY? / DISPOSITION
COMMENTS

CONFIDENTIAL MEDICAL RECORDS - Upon release or treatment completion, send record to this health department: ______

southeastern national tuberculosis center (sntc) u http://sntc.medicine.ufl.edu u 888-265-7682 u