Rossdonaldson1 at 22:00, 31 August 2022

2022-08-31T22:00:35Z

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		[[Category:Admin]]

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2020-04-28T06:46:33Z

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Jochickabee: Created page with "CC: |PATIENT AGE|

HPI:

REFERRED BY:
[ ] Self
[ ] Failed primary screen
[ ] GLA Employee Symptom Self-Referral Tool
[ ] Supervisor
..."

2020-04-28T06:42:48Z

Created page with "CC: |PATIENT AGE| HPI: REFERRED BY: [ ] Self [ ] Failed primary screen [ ] GLA Employee Symptom Self-Referral Tool [ ] Supervisor ..."

New page

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

Wlava:Enhanced Screening Tent Employee Template - Revision history

Rossdonaldson1 at 22:00, 31 August 2022

Jochickabee: Blanked the page

Jochickabee: Created page with "CC: |PATIENT AGE| HPI: REFERRED BY: [ ] Self [ ] Failed primary screen [ ] GLA Employee Symptom Self-Referral Tool [ ] Supervisor..."

Jochickabee: Created page with "CC: |PATIENT AGE|

HPI:

REFERRED BY:
[ ] Self
[ ] Failed primary screen
[ ] GLA Employee Symptom Self-Referral Tool
[ ] Supervisor
..."