WLAVA:Enhanced Screening Tent Employee Template/pl

Machine-translated from the English original. Only the English page can be edited.

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 ból głowy/dreszcze or T > 99.9F [ ] Cough (new or worse than usual) [ ] ból gardła (new or worse than usual) [ ] Shortness of breath or trouble breathing (new or worse than usual) [ ] ciało or mięsień aches (new or worse than usual) [ ] biegunka (new or worse than usual) [ ] Severe zmęczenie [ ] 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 ból w klatce piersiowej, 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 ból głowy (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 ból głowy at ANY punkt (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 ból głowy (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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Authors

Jonie Hsiao MD, Daniel Ostermayer, MD

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