View source for WLAVA:Enhanced Screening Tent Employee Template

<small>CC: |PATIENT AGE|<p>
 <br>
HPI:<br>
 <br>
REFERRED BY:<br>
[ ] Self<br>
[ ] Failed primary screen<br>
[ ] GLA Employee Symptom Self-Referral Tool<br>
[ ] Supervisor<br>
[ ] Employee Health<br>
[ ] Other: (free text box)<br>
 <br>
SYMPTOM SCREEN (select all that apply):<br>
[ ] Subjective fevers/chills or T > 99.9F<br>
[ ] Cough (new or worse than usual)<br>
[ ] Sore throat (new or worse than usual)<br>
[ ] Shortness of breath or trouble breathing (new or worse than usual)<br>
[ ] Body or muscle aches (new or worse than usual)<br>
[ ] Diarrhea (new or worse than usual)<br>
[ ] Severe fatigue<br>
[ ] Other: (free text box)<br>
 <br>
EXPOSURE SCREEN:<br>
[ ] Close contact with CONFIRMED COVID19 case (within 14 days of Sx onset)<br>
[ ] Healthcare worker (including EMT, paramedic, etc)<br>
[ ] Works in a long-term care facility (CLC, CalVet, New Vista, community SNF, etc)<br>
[ ] Works in a group living facility (homeless shelter, board & care, DOM, New Directions, US Vets, etc)<br>
[ ] Works in HD clinic or infusion center<br>
 <br>
EMPLOYEE PATIENT DETAILS:<br>
[ ] Job description:<br>
[ ] Physician<br>
[ ] Nurse<br>
[ ] Respiratory Therapist<br>
[ ] Intermediate Care Technician<br>
[ ] Other: (free text box)<br>
[ ] Job location: (free text box)<br>
 <br>
EMPLOYEE PATIENT EXPOSURE:<br>
[ ] Date of Suspected Exposure: (free text box for date)<br>
[ ] Patient was wearing a mask (if unsure leave unchecked)<br>
[ ] Aerosol generating procedure being performed at time of exposure (intubation, CPR, bronchoscopy,<br>
BiPAP, nebulizer treatment, etc)<br>
 <br>
PPE Worn By Employee Patient (select all that apply):<br>
[ ] Surgical mask<br>
[ ] N95 respirator or equivalent (PAPR, elastomeric respirator)<br>
[ ] Eye protection<br>
[ ] Face shield<br>
[ ] Gloves<br>
[ ] Gown<br>
 <br>
How long was exposure:<br>
[ ] Less than 5 minutes<br>
[ ] Greater than 5 minutes<br>
Proximity to the Patient during exposure:<br>
[ ] Less than 6 feet<br>
[ ] Greater than 6 feet<br>
 <br>
SOCIAL HISTORY:<br>
[ ] Domiciled in private residence<br>
[ ] Undomiciled (includes living in tent, car, etc)<br>
 <br>
PMHx:<br>
ACTIVE PROBLEMS<br>
|ACTIVE PROB LIST-SHORT|<br>
 <br>
ALLERGIES:<br>
|ALLERGIES|<br>
 <br>
VITALS:<br>
T: |TEMPERATURE|<br>
P: |PULSE|<br>
R: |RESPIRATION|<br>
BP:|BLOOD PRESSURE|<br>
Pain: |PAIN|<br>
Pulse Ox: |PULSE OXIMETRY|<br>
 <br>
PHYSICAL EXAM:<br>
GEN: Well-appearing, No apparent distress<br>
Resp: Normal work of breathing, speaking in complete sentences<br>
Neuro: A&Ox3, Gait: steady, moving all extremities, no gross focal deficits<br>
 <br>
ASSESSMENT:<br>
Patient is afebrile and with unremarkable respiratory vital signs. Patient at baseline ambulatory status,<br>
non-toxic appearing, and speaking in full sentences. Based on the limited examination there is a low<br>
suspicion for serious bacterial infection or systemic illness.<br>
[ ] COVID-19 suspected, met testing criteria.<br>
[ ] COVID-19 suspected, did not meet testing criteria.<br>
[ ] COVID-19 suspected, testing refused.<br>
[ ] COVID-19 not suspected.<br>
[ ] Other: (free text box)<br>
 <br>
PLAN:<br>
[ ] Encouraged patient to continue with symptom alleviation.<br>
[ ] Encouraged to return if has significant worsening of symptoms including chest pain, shortness of<br>
breath, or inability to care for self.<br>
 <br>
DISPOSITION:<br>
[ ] No concern for COVID, allowed to enter medical center <br>
[ ] Home<br>
[ ] ED, handoff given to ED attending: (text box for name)<br>
 <br>
EMPLOYEE RETURN TO WORK GUIDANCE:<br>
[ ] Employees with pending COVID-19 who ARE ASYMPTOMATIC:<br>
- If this employee was tested following an exposure, employee should remain on duty but must<br>
wear a mask for 14 days. If employee has no known exposure, employee can return to work and<br>
should follow current GLA masking policy.<br>
- Encourage they take their temperature twice per day and report T> 99.9F.<br>
- If they become symptomatic they must report to Employee Health (310-268-3522)<br>
 <br>
[ ] Employees pending COVID-19 test results who HAVE ANY SYMPTOMS OF COVID-19:<br>
- Off duty minimum of 7 days from onset of symptoms.<br>
- Return to work when all of the following criteria are met:<br>
o Must be afebrile (T <100.0F) without the use of fever-reducing medications.<br>
o Improvement in respiratory symptoms (i.e., cough, shortness of breath)<br>
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19<br>
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours<br>
apart (total of two negative specimens)<br>
 <br>
[ ] Employees with a POSITIVE COVID-19 test who HAVE ANY SYMPTOMS OF COVID-19:<br>
- Off duty minimum of 7 days from onset of symptoms.<br>
- Return to work when all of the following criteria are met:<br>
o Resolution of fever (T <100.0F) without the use of fever-reducing medications.<br>
o Improvement in respiratory symptoms (i.e., cough, shortness of breath)<br>
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19<br>
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours<br>
apart (total of two negative specimens)<br>
 <br>
[ ] Employees with a POSITIVE COVID-19 test who ARE ASYMPTOMATIC:<br>
- Exclude from work until 10 days have passed since the date of their first positive COVID-19<br>
diagnostic test and criteria below is met. If the patient develops symptoms at any time, they<br>
should report to Employee Health (310-268-3522).<br>
- Return to work criteria:<br>
o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19<br>
from at least two consecutive nasopharyngeal swab specimens collected > 24 hours<br>
apart (total of two negative specimens)<br>
 <br>
[ ] Employees with a negative COVID-19 test who HAVE ANY SYMPTOMS OF COVID-19:<br>
- If an alternative diagnosis has been made (i.e., tested positive for influenza), criteria for return<br>
to work should be based on that diagnosis.<br>
Otherwise, follow criteria below:<br>
o IF patient has had objective fever at ANY point (T >99.9F):<br>
▪ Off duty minimum of 7 days from onset of symptoms.<br>
▪ Return to work criteria (must meet all):<br>
• Must be afebrile off antipyretic and have improving symptoms for 3 days.<br>
• Must wear mask for 14 days from onset of symptoms.<br>
o IF patient has never had objective fever (T > 99.9F):<br>
▪ Off duty while symptomatic.<br>
▪ Return to work criteria (must meet all):<br>
• May return 24 hours after improvement in respiratory symptoms.<br>
• Must wear mask if persistently coughing. <br>
</small>

==Other WLAVA Administrative pages==
{{Special:Prefixindex/WLAVA |hideredirects=1}}
[[Category:Admin]]