Southern Health Partners, Treatment Protocol - Chronic Care

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Southern Health

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TREATMENT PROTOCOLS
Medical Department – County Jail

CHRONIC CARE

Treatment Protocols – Revised May 2014 – Revised November 2014- Confidential Work Product of SHP & Physician
Not to be a substitution for prudent medical judgment
Page | 6

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TREATMENT PROTOCOLS
Medical Department – County Jail

CHRONIC CARE- QUICK GLANCE
When setting up chronic care, you need to use the Nursing Chronic Disease Flow sheet, the Master Problem
List, the Chronic Care Initial Data Medical Form, and the Chronic Care Tracking Log.
This is a guideline, and not a replacement for your Provider’s actual treatment regimen order which is patient
specific, or your own sound medical judgment.
Chronic Care Conditions to be monitored:

HIV/AIDS
Hypertension
Diabetes
Asthma
Seizures
Diagnosed Mentally Ill
Tuberculosis
Hyperlipidemia
Coumadin Therapy
Digoxin
Thyroid - TSH/Free T4

Upon placing the patient in Chronic Care for consistent monitoring.
1. The nurse will add the patient’s name to the Chronic Care Tracking Log form and schedule the patient
to see the Physician provider at their next on-site visit.
2. The nurse will complete the Master Problem List form and place it in the front of the patients’ medical
record. This form is to be used to track any condition interventions for the patient. It is an easy
glance for the Physician Provider when they review chronic care charts.
3. The Physician/Provider must complete the Chronic Care Initial Data Medical Form.
4. The nurse will then schedule the patient for follow up accordingly.
HIV/AIDS
1. Refer to Medical Provider, and then based on his/her assessment, may be referred to Infectious
Disease Specialist;
2. Consider Diet- double portions if weight is an issue, or if on meds. Weight to be documented monthly.
3. MVI daily; Flu Vaccine annually; Pneumovax every 5 years.
4. Labs: CD4 and HIV viral load (unless appointment with ID Specialist)
Hypertension
1. BP checks as ordered by MD
2. Flu Vaccine annually;
3. At 3 month intervals: CBC, CMP, Lipid Profile, Urine dipstick
Diabetes
1. Diet- Special diet for diabetics
2. At 3 month intervals: Lipid panel, U/A, CMP, HbA1C

Provider’s Initial/Date:

Treatment Protocols – Revised May 2014 – Revised November 2014- Confidential Work Product of SHP & Physician
Not to be a substitution for prudent medical judgment
Page | 7

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TREATMENT PROTOCOLS
Medical Department – County Jail

Asthma
1. Peak Flow Meter testing at H&P, document findings
2. Flu Vaccine annually
Seizures
1. To be housed on bottom bunk, downstairs
2. Labs at Intake, or shortly thereafter: Dilantin, Depakote, (Keppra if applicable), then at 3 month,
then at 6 month intervals
Diagnosed Mentally Ill Patient
Lithium at 3 months and then at every 6 month intervals, unless otherwise indicated.
Tuberculosis
If TB test is over 10mm, unless immune compromised, then 5mm:
1. CXR to be done
2. If patient is put on INH, then patient needs to be on B-6 daily. Will need LFTs monthly.
3. Use TB Flow sheet
4. Notify Health Department if confirmed positive.
Hyperlipidemia
Blood Lipid Panel and Liver Function at 3 months, and then at every 6 month interval
Coumadin Therapy
1. Patient with INR within1 week of admission date
2. Medical Provider to write orders based on results
Digoxin
1. Digoxin level on admission, or shortly thereafter, not to exceed 10 days later.
2. Level then to be drawn at every 6 month interval
Synthroid (Thyroid)
1. TSH and Free T4 level on admission, or shortly thereafter, not to exceed 10 days later.
2. Level then to be drawn at every 6 month interval
This is a guideline, and not a replacement for your Provider’s actual treatment regimen order, or
your own sound medical judgment.

1Provider’s Initial/Date:

Treatment Protocols – Revised May 2014 – Revised November 2014- Confidential Work Product of SHP & Physician
Not to be a substitution for prudent medical judgment
Page | 8

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NURSING CHRONIC DISEASE FLOWSHEET
Instructions: Nurses are to use this information in documenting medical information for chronic care patients on a monthly
basis. All information is then to be reviewed by the Medical Director, with his/her initials at the bottom signifying review of
such. Any additional orders are to be written by the Medical Director and done by the nursing staff. All results of such orders
should then be communicated to the Medical Director timely for any additional orders or follow-up.

Patient Name (Last, First, Middle):
Birthdate:

Sex: M or F Allergies:

Intake Date:

Date entered into Chronic Care:

Condition(s)
Review Date:
Vital Signs:
BP:
T:
P:
R:
Wt:

Review Date:
Vital Signs:
BP:
T:
P:
R:
Wt:

Medications:

Med Compliant?

Special Diet?

Diet Compliant?

Patient Education given on Diet;
Disease Process; Exercise, Smoking
Cessation; ETOH Cessation?
Other:

Any issues regarding
condition control?

Lab Data: (circle those to be done

and then list data information)

CBC
UA
BMP
Hgb A1C
HIV VL
CD-4
INR
Flu Vaccine
Drug Levels
PPD
Chol/Tri

Nurse’s Initials:

Clinician Initials/Date:

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MASTER PROBLEM LIST
Instructions: To be used as a summary of the patient’s medical issues - Chronic and Acute Conditions.
Chronic Conditions are classified as (but not limited to): Diabetes (ID/NID), Hypertension, Pregnancy, HIV/AIDS, Asthma,
Seizures, Diagnosed Mental Illness, CHF, Hepatitis.
Acute Conditions are classified as (but not limited to): Bone fracture; Sore Throat; or Earache.

Patient’s Name: (Last/First/Middle)
ID#

DOB

Intake Date

Sex
H&P completed

Allergies
PPD Completed

Chronic
Acute
Date
Date
Condition
Condition
Problem
Diagnosis
Medications
Seen by
()
()
Identified
Medical
'--------1---------+---+-----+----------t---------i

MD
Initials

0
0
0
0
0
0
0
Page:

of
Form Updated 12/2013

SHP 000335

CHRONIC CARE CLINIC – INITIAL MEDICAL DATA FORM

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Patient Name (Last, First):
Site Name/State:
Intake Date:

Birthdate:
Date entered into Chronic Care:

Sex: M or F

Chronic Condition (check all that apply):  Asthma/COPD
 Hypertension
 TB
 Seizures
 Diabetes
 HIV/AIDS
 High Cholesterol
 Pregnance
 Mental Illness
 Other:
To be completed by nurse:
Personal Risk Factors
Family History
Surgeries/Hospitalizations
Y
N
Y N
Smoking: Pack/Month:
Anemia
High Blood Pressure
Asthma
High Cholesterol
Heart Disease
Obesity
High Blood Pressure
Diabetes
Diabetes
Alcohol:
Kidney Disease
Substance Abuse:
Cancer:
Injection Drug Use
Multiple Sex Partners
Unsterile
Tattooing/Piercing
Notes/General Description of above history:

Mental Illness
Sick Cell Disease
Tuberculosis:

To be completed by nurse for chronic care condition. Circle YES answers. Mark through other conditions that do not apply.

HYPERTENSION/DIABETES/
CARDIOVASCULAR
Date of Dx:
Chest Pain
Shortness of Breath
Palpitation
Leg Swelling
Previous Heart Attack
Previous CVA/Stroke
Rheumatic Fever
Headaches
Syncope/Dizziness
Hypoglycemic Episodes
Kidney Disease
Weight Gain/Loss
Blurred Vision
Foot Problems
Nocturia
Polyuria

SEIZURES
Date of Dx:
Aura
Postictal State
# of Seizures in past month:
Type of Seizures
Gum Disease
Date of Last Seizure:
LOC
Other Neuro Symptoms?
Headache
Incontinence
Paralysis

ASTHMA/COPD/TB/
PULMONARY
Date of Dx:
Wheezing
# of ER visits in past 3
months:
Hx of Intubations
Inhaler Use
Prior Systemic Steroids
Activity Intolerance
GERD
Allergies
Exposure to Asbestos
Hemoptysis
Fever
Liver Disease
Night Sweats
Weight Loss
Persistent Cough

HIV/AIDS/HCV INFECTION
Date of Dx:
Anorexia
Malaise
Oral Lesions
Nausea/Vomiting
Constipation
Diarrhea
Anorectal pain/Lesions
Weight Loss/Gain
TB Infection
Hx Pneumonia
AIDS Diagnosis
Abdominal Pain/Swelling
Abnormal PAP Smear
Jaundice
Joint Pain
Pruritis

SHP 000336

CHRONIC CARE CLINIC – INITIAL MEDICAL DATA FORM
NOTES: List Details of any
Circled Answers:

NOTES: List Details of any
Circled Answers:

List Current Medications:

Education Provided to
Patient (circle)
Disease/Condition
Medication Management
Nutrition
Smoking/Tobacco Use
Exercise
Alcohol/Substance Abuse
Other:

Nurse’s Initials/Date:

Clinician’s Initials/Date:

The Clinician must complete the next page of the Physical Exam.

SHP 000337

CHRONIC CARE CLINIC – INITIAL MEDICAL DATA FORM
To be completed by the Clinician Only:
PHYSICAL EXAM: Vital Signs:

Temp:

Blood Pressure:

Height:

Weight:

Pulse:

Resp

Peak Flow:

HEENT:
Neck:
Heart:
Lungs:
Abdomen:
Extremities:
GU/rectal
Other:
Labs to be done:

 Hgb A1C
 BUN
 Other:

 Hct ALT  T.Chole.
 CBC UA  HIV

 CD4 Cell
 AST

ASSESSMENT/Diagnoses / Degree of Control:

PLAN:
Medication Changes:
Immunizations
Diagnostics:
Other Tests:
Monitoring:

(circle)
(circle) EKG;

Hgb
HDL

Influenza Vaccine
Pneumococcal Vaccine
Chest X-ray; Lipid Studies
PAP Smear
RPR

N/A

Hepatitis Panel

BP: Check
times per day/week/month
Glucose: Check
times per day/week/month
Peak Flow: Check
times per day/week/month
Other:

Is any referral needed?

If yes, what specialist

What timeframe (consider jail transport)
Clinician’s Signature/Date:
Nurse to take off orders as indicated and follow through. Put completed form in patient’s medical record.

SHP 000338

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CHRONIC ILLNESS TRACKING LOG

Chronic Conditions include (but not limited to):
Asthma, Hypertension, HIV/Aids, Diabetics (ID/NID),
Pregnancy, Seizures, Diagnosed Mental Illness,
CHR, Hepatitis, High Cholesterol

Facility/State:
Please note all information regarding listing Chronic Condition Patients. The physician should perform
initial hands-on assessment of the patient regarding their condition. Chronic condition review clinic dates
will be established by the physician. This form must be maintained at the site for review by all medical
staff and the site physician. Once patient information has been completed across this form, enter patient
information on new form. File all completed logs in a file in medical office labeled “Chronic Illness Logs”.
Name (last, first)
List Chronic Condition

Intake
Date

Date entered
into Chronic
Care Clinic

Date Seen
by Physician

Next
Clinic
Date

Done



Next
Clinic
Date

Done



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