Patient’s Name: _______________________________________ DOB: ____________________
Treatment of Latent Tuberculosis Infection (LTBI): Monitoring Flow Sheet
Medication orders:
Physician:
Medication start date:
Anticipated stop date:
Risk status (circle one):
Normal
Other MD orders (labs, etc.):
High (i.e., close contact, documented recent converter, immunocompromised, stable fibrotic changes on CXR, age < 5 yrs)
All patients should have the following:
Face-to-face follow-up evaluation at least monthly. Routine laboratory testing generally is not indicated.
Education about possible adverse effects. Advise patient to stop treatment and seek medical evaluation if serious adverse effects occur.
Patients receiving INH-RPT require a monthly physical exam for the presence of jaundice, liver tenderness, or rash.
If patient becomes pregnant while receiving INH-RPT, discontinue regimen and seek medical evaluation.
Date:
TB symptoms?: (i.e., weight loss, night sweats,
prolonged cough, bloody sputum)
Date of last clinic visit
Poor appetite (INH//RIF/RPT)
Nausea/vomiting (INH//RIF/RPT)
SIDE EFFECTS
RUQ abdominal tenderness (INH/RIF/RPT)
Tea/coffee colored urine (INH/RIF/RPT)
Unusual fatigue (INH/RIF/RPT)
Dizziness (RPT)
Rash/itching (INH/RIF/RPT)
Yellow skin/eyes (INH/RIF/RPT)
Numbness/tingling in arms/legs (INH)
Fever for 3 days (INH/RIF/RPT)
Need to notify MD/nurse if side effects
TEACHING
Signs/symptoms of active TB disease
Avoiding alcohol use
Orange urine/tears normal (RIF/RPT)
Effect on hormonal contraceptives (RIF/RPT)
Avoiding pregnancy (RPT)
Importance completing regimen
Importance of notifying providers if moving
DOSES
Adherence: # missed doses this month?
Medications dispensed / DOT (INH-RPT)
Total # doses taken this month/week (INH-RPT)
Date of next MD visit
Nurse initials
Y = Yes
N = No
N/A = Not Applicable
P = See Progress Notes (on back)
INH = Isoniazid
RIF = Rifampin
RPT=Rifapentine
Nurse signature(s) _______________________________________________________________________________________________________________________
Complete when closing case: Total # doses ingested: _______ Total # months/weeks (INH-RPT) on therapy: _____ Treatment completed: Yes No
Developed by the Minnesota Department of Health, TB Prevention and Control Program, www.health.state.mn.us/tb (651) 201-5414 Revised, May 2012
Progress Notes
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