6 .5 Return an updated Acknowledgement Form to the referring DOTS facility

As soon as a definitive diagnosis has been made at the Treatment Center, you need to inform the referring DOTS facility of the diagnosis and plan for the patient. This is done using the same Acknowledgement Form that is used during screening. This is accomplished in duplicate copies, one for the referring facility through the patient and the other attached to the patient’s records in the Treatment Center. Tick the box for “Final diagnosis”. On this form the physician writes the name of the referred patient, the pertinent laboratory findings particularly DST, the final diagnosis, and the recommendations. If however, the patient has not called or returned to the Treatment Center to pick up his results, the Acknowledgement Form will be sent by facsimile to the referring facility with request for assistance to locate the patient. All efforts should be done to contact the patient, e.g., by land or cell phone, or by a visit. An example of the Acknowledgement Form for final diagnosis is shown in the next page.

Date:

To:

REPUBLIC PHILIPPINES

Acknowledgement Form

October 11, 2005

Dr. A. Madrid Sampaguita Health Center Tondo, Manila

Jose A. Balagtas

AFS Culture DST (released Oct.10, 2005)

}4/25/05 3+ M. tuberculosis Resistant to H,R,E,S 4/26/05 4+ M. tuberculosis susceptible to Z Km, Cfx, Ofx, Lfx

Final diagnosis is MDR-TB Initial Diagnosis 3 Final Diagnosis

Thank you for referring your patient diagnosis/management. , for further TB

Pertinent findings/ Laboratory examinations:

Notify referring MD/ treatment facility regarding the patient’s diagnosis and plan of treatment. Tick final diagnosis for patients with results of sputum test

Plans/Recommendations:

For category IV treatment Please inform patient that he is ready for enrollment. Please contact the number below for any queries and further instructions.

Clinic Physician: Contact numbers: Treatment Center: Programmatic Management of Drug - Resistant TB (PMDT)

Dr. Dan. A. Rivera 742-1534/ 781-3761 to 65 loc. 146 KASAKA-QI MDR-TB Housing Facility

To be accomplished In duplicate copies: One copy for the Referring physician or facility and one copy attached to the Screening Form at the Treatment Center