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