WLAVA:Enhanced Screening Tent Employee Template

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.

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