Discharge Planning TB

NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BUREAU OF TUBERCULOSIS CONTROL

HOSPITAL DISCHARGE APPROVAL REQUEST FORM
Please complete this form in entirety and fax to 844-713-0557 (toll-free)
SECTION A: Patient Contact Information
Patient name: DOB: _______/_______/_______

mm dd yyyy
Tel. #: (1) ( ______ )_________ – ______________ (2) ( ______ )_________ – ______________
Address: Apt.: City: State: Zip:
Emergency contact name: Relationship to patient: Tel. #: ( ) –

SECTION B: Discharge Information
Discharging facility: Discharging facility tel. #: ( ) –

Address: Fl.: City: State: Zip:
Patient medical record #: Date of admission: / / Planned discharged date: / /
mm dd yyyy mm dd yyyy
Discharged to: 䡺 Home (if not the same address as above, fill in address below)
䡺 Shelter 䡺 Skilled nursing facility 䡺 Jail/Prison 䡺 Residential facility 䡺 Other facility
Name of facility: Tel. #: ( ) –
Address: Apt./Fl.: City: State: Zip:
Is patient scheduled to travel outside of NYC? 䡺 Yes 䡺 No If yes, specify date/destination:
SECTION C: Patient Follow-Up Appointment
Patient follow-up appointment date: / /

mm dd yyyy
Physician assuming care: Tel. #: ( ) – Cell. #: ( ) –
Address: City: State: Zip:
Potential barriers to TB therapy adherence: 䡺 None 䡺 Adverse reactions 䡺 Homelessness
䡺 Physical disability (specify) 䡺 Medical condition (specify)
䡺 Substance use (specify) 䡺 Mental disorder (specify) 䡺 Other
SECTION D: Laboratory Results
Dates of three most recent
acid fast bacilli (AFB) smears Specimen source Acid fast bacilli (AFB) smear results
_______/_______/_______ 䡺 Positive Grade: ______ 䡺 Negative

SECTION E: Treatment Information
Date TB therapy initiated: / / Interruption in therapy? 䡺 Yes 䡺 No If yes, state the reason and duration
mm dd yyyy
of the interruption?
TB medications 䡺 INH _____ mg 䡺 RIF _____ mg 䡺 PZA _____ mg 䡺 EMB _____ mg 䡺 SM _____ mg 䡺 Vitamin B6 _____ mg
at discharge:
䡺 Injectables (specify) 䡺 Other TB meds (specify)
Frequency: 䡺 Daily 䡺 2x weekly 䡺 3x weekly 䡺 Other
Was a central line (i.e. PICC) inserted on the patient? 䡺 Yes 䡺 No
Number of days of medications supplied to patient at discharge Patient agreed to be on DOT? 䡺 Yes 䡺 No
Print name of individual filling out this form: Date: / /

mm dd yyyy
Name of responsible physician at the discharging facility: License #:
Signature of responsible physician at the discharging facility: Tel. #: ( ) –
COMPLETED BY THE HEALTH DEPARTMENT BTBC NUMBER:

Discharge approved: 䡺 Yes 䡺 No Action required before discharge:
Reviewed by: Date: / /

NAME OF HEALTH OFFICER/DESIGNEE mm dd yyyy
TB 354 (11/10)
Guidelines for How to Complete and Submit the Mandatory TB
Hospital Discharge Approval Request Form (TB 354)
As of June 16, 2010, Article 11 of the New York City Health Code mandates health care providers to obtain approval
from the New York City Department of Health & Mental Hygiene (DOHMH) before discharging infectious TB patients
from the hospital.
Discharge of an Infectious (sputum smear positive) Tuberculosis Patient

Health care providers must submit a Hospital Discharge Approval Request Form (TB 354) at least 72 hours prior to
the anticipated discharge date. The DOHMH will review the form and approve or request additional information before
the patient can be discharged from the health care facility.
Weekday (non-holiday) Discharge: The written discharge plan should be submitted by fax to the Bureau of TB
Control between 8am-5pm. Bureau of TB Control staff will review the discharge plan and, within 24 hours, notify the
provider of approval or inform the provider of any additional information/actions required for approval prior to
discharge.
Weekend and Holiday Discharge: All arrangements for discharge should be made in advance when weekend or
holiday discharge is anticipated.
For detailed information about hospital admission and discharge of TB patients, please refer to the New York City
DOHMH Bureau of TB Control Policies and Protocols manual available online at http://www1.nyc.gov/site/doh/health/
health-topics/tb-hosp-manual.page
Instructions for Completing the Hospital Discharge Approval Request Form (TB 354)
Section A Patient contact information: Provide the patient’s contact information including patient’s name, a verified
address and telephone numbers. In addition, include a name of an emergency contact, the contact’s relationship to
the patient and the contact’s verified phone number.
Section B Discharge information: Provide the name and phone number of the discharging facility, the medical
record number of the patient at the facility, date the patient was admitted, planned discharge date, and the location
to which the patient is being discharged. If the patient will be discharged to a location other than the patient’s
address listed in Section A, a facility name (if applicable), address and phone number must be provided. If the patient
plans to travel, provide the date and destination.
Section C Patient follow-up appointment: Provide the patient’s follow-up appointment date, as well as the name
and contact information of the provider who is assuming patient care. Check all potential obstacles that may affect
TB therapy adherence.
Section D Laboratory results: Report the results of the three most recent acid fast bacilli (AFB) smears including the
date of specimen collection, specimen source, and AFB smear results and/or grade.
Section E Treatment information: Fill in the date TB treatment was initiated. If there were any treatment
interruptions, indicate the reason and number of days treatment was stopped. Check the box next to each
prescribed drug and state dosages for each drug. Write in drugs and dosages for drugs not specified. Specify the
treatment frequency by checking one of the three boxes, or writing in a different treatment schedule. State whether
the patient will have a central line inserted at the time of discharge. If TB medication will be supplied to the patient at
discharge, write the number of days for which the medication will be supplied. State whether the patient agreed to be
on directly observed therapy (DOT).
After Section E, the name of the person completing the form should be printed and the authorized physician at the
discharging facility must print and sign their name, and provide their medical license number and telephone number.
Forms should be faxed to the DOHMH at 844-713-0557 (toll-free).

If you have questions about completing the form, please call 311 and ask to speak to a Bureau of TB Control
physician.
To fulfill State requirements for communicable disease reporting, health care providers must report all suspected or
confirmed TB cases to the DOHMH via Reporting Central (formerly Universal Reporting Form (URF)). Instructions for
reporting a case of TB can be found at http://www1.nyc.gov/site/doh/providers/reporting-and-services/hcp-urf.page
NOTE: A discharge approval request form does not substitute required case reports.
TB 354 (11/10)

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NEW YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE

BUREAU OF TUBERCULOSIS CONTROL

Patient name: DOB: ___/_/_____

Address: Apt.: City: State: Zip:

Emergency contact name: Relationship to patient: Tel. #: ( ) –

Discharging facility: Discharging facility tel. #: ( ) –

Patient follow-up appointment date: / /

___/_/_ 䡺 Positive Grade: __ 䡺 Negative

Print name of individual filling out this form: Date: / /

Signature of responsible physician at the discharging facility: Tel. #: ( ) –

COMPLETED BY THE HEALTH DEPARTMENT BTBC NUMBER:

Reviewed by: Date: / /

Discharge of an Infectious (sputum smear positive) Tuberculosis Patient

Forms should be faxed to the DOHMH at 844-713-0557 (toll-free).

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