Public Health Department Policy & Procedure Manual Example

POLICY TITLE: Cholestech: Lipid and Glucose Screening and Testing

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POLICY TITLE: Cholestech: Lipid and Glucose Screening and Testing

EFFECTIVE DATE: 07/16/2012


AUTHORIZED BY: Jen Rombalski, Health Officer
To assure access to high quality/low cost lipid and glucose screening for adults in Buffalo County, in order to detect individuals with abnormal levels, who may be at risk for Cardiovascular Disease and Diabetes. Second, to council and educate clients regarding the meaning of their results, optimal results, and health promoting diet and life style measures. Third, to make appropriate referrals to their primary health care provider for further assessment and care as needed.
Buffalo County Public Health periodically assesses the need for community cholesterol

screening clinics. The ability to provide this screening is part of the assurance role of

Buffalo County Public Health.
Registered Dietician

Public Health Nurse

Public Health Aide

  1. Outreach/Advertising

A. Potential Sources

1. Radio

2. Newspaper

3. Flyers; distributed to clinics and throughout the community

B. Content ideas for outreach

1. Date, time, place

2. Cost

3. Buffalo County Public Health Dept.

4. Contact telephone #

5. Location

6. Call for an appointment

  1. Scheduling

A. PHN, RD, and PH Aide coordinate schedules to find 1 am/mo to

hold screenings

B. Refer callers to PHN

C. Slot 30 min. appointments; 8:30-11:00am

D. Review the following pre-test instructions with client:

1. NPO for 12 hours prior to appointment time-nothing to eat or drink

except H20

2. Obtain client telephone number

3. Obtain client’s mailing address so an appointment reminder card may be


4. Cost of testing

5. Directions to our office and to check in at the front desk

6. Ask if and when client has had their cholesterol tested at BCDHHS in the

past (pull old records for comparing results)

E. Telephone or mail client reminder Post-Card within 1 week prior to

appointment date informing client to fast for 12 hours before appointment.

  1. Screening

  1. Paperwork

  1. Give client a Notice of Privacy Practices Regarding Health Information and have client sign an Acknowledgement of Receipt of Notice of Privacy Practices Regarding Health Information.

  2. Have client complete and sign History & Consent.

  3. Have client complete a Food Record, if they plan to meet with RD.

  1. PH Aide obtains client height and weight and records on Screening Record.

  2. PH Aide performs Lipid Panel/Glucose testing, see Capillary Blood Collection and Lipid and Glucose Screening Policies and Procedures.

  3. PH Aide records results on Screening Record form.

  4. PHN obtains client blood pressure and records on Screening Record.

  5. PHN calculates client’s ideal weight range using the Body Mass Index Table and record on Screening Record.

  1. Testing
  1. Remove Cholestech LDX Lipid plus Glucose Cassette from refrigerator and allow to warm to room temperature for 10 minutes.

  2. Meanwhile, set up the following supplies:

  • Cholestech LDX Analyzer, power source, and printer

  • Non-sterile gloves

  • Alcohol swabs

  • Gauze

  • Cholestech LDX capillary tube

  • Capillary plunger

  • Lancet

  • Biohazard waste container

  • Patient Result Log

  1. Apply non-sterile gloves

  2. Client should sit quietly for five minutes before the blood sample is collected.

  3. Put a capillary plunger into the end of a Cholestech capillary tube with the red mark. Set it aside.

  4. Choose a spot on the side of one of the center fingers of either hand. To help increase blood flow, the fingers and hands should be warm to the touch. To warm the hand, you can:

  • Wash the client’s hand with warm water,

  • Apply a warm (not hot) compress to the hand for several minutes

  • Gently massage the finger from the base to the tip several times to bring the blood to the fingertip.

  1. Clean the site with an alcohol swab. Dry thoroughly with a gauze pad before pricking the finger.

  2. Firmly prick the selected site with a lancet.

  3. Squeeze the finger gently to obtain a large drop of blood. Wipe away this first drop of blood, as it may contain tissue fluid.

  4. Squeeze the finger gently again while holding it downward until a second large drop of blood forms. Do not milk the finger. The puncture should provide a free-flowing drop of blood.
  5. Hold the capillary tube horizontally by the end with the plunger. Touch it to the drop of blood without touching the skin. The tube will fill by capillary action up to the black mark. Do not collect air bubbles. If it is necessary to collect another drop of blood, wipe the finger with gauze then massage again from base to tip until a large drop of blood forms.

  6. Fill the capillary tube within ten seconds.

  7. Wipe off any excess blood and have the patient apply pressure to the puncture until the bleeding stops using pressure dressing as needed.

  8. Remove cassette from its pouch. Do not touch the black bar or the brown stripe. Put the cassette on a flat surface.

  9. Apply capillary blood sample in sample well of cassette. Keep cassette flat after applying sample.

  10. Press RUN on analyzer. In a few seconds the screen will read: “Selftest running”, “Selftest OK”

  11. The cassette drawer will open. The screen will read: “Load cassette and press RUN”.

  12. Place the cassette into the drawer of the Analyzer at once. The black bar must face the Analyzer. The brown stripe must be on the right.

  13. Press RUN. The drawer will close. During the test the screen will read “(test names) Test Running”.

  14. Put everything that touched the blood sample or control in a biohazard waste container, except gauze pad or band-aids that are minimally contaminated with blood may go into basic disposal system.

  15. When the test is complete, the Analyzer will beep. The screen will read: “(test name) = ###”, and “warnings”.

  16. Press DATA to show more results.

  17. When the results are outside the measuring range, the screen will read: “(test name) ### or (test name) ###”.

  18. If there is a problem with the test, a message will appear on the screen. See the Cholestech LDX User Manual if this happens.

  19. When the drawer opens, remove the cassette. Put it in a biohazard waste container. Leave the analyzer drawer empty when not in use.

  20. Record the results on the Cholestech Lipid Panel and Glucose Results Form and on the Patient Results Log.
  1. PHN Counseling and Education

  1. PHN reviews Screening Record, and History & Consent forms.

  2. PHN educates and uses motivational interviewing to counsel clients on the following topics as needed:

    • Client lipid panel/glucose results

    • Exercise/activity

    • Blood pressure

    • Weight control

    • Tobacco

    • Alcohol

    • Diabetes

    • Warning signs of heart attack and strokes

    • Diet/Nutrition prn, especially if client declines offer to see RD

    • Recommended optimal results for lipids and glucose

    • Stages of change and the change process

  1. PHN documents education and counseling on Public Health Nurse Summary form.

  2. PHN makes 2 copies of the Screening Record, and gives one to the client and mails/faxes the other to the client’s primary care provider.

  3. Educational Materials are provided to client prn

    • Brochures

    • Web sites and web based interactive tutorials at PubMed

  1. PHN offers all clients dietary counseling with RD

  1. RD Counseling and Education (by onsite WIC/PH RD)

  1. RD reviews Screening Record, History & Consent, and Food Record forms.

  2. Dietary counseling with RD may include:

    • American Dietary Guidelines

    • Dietary supplements

    • Eating out

    • Reading food labels

    • Portion sizes

    • Making healthier food choices

    • Recipe substitutions
    • Other diet/nutrition/health topics prn.

  1. RD documents on Registered Dietician Summary.

  2. Educational Materials prn

    • Brochures

    • Food models showing portion sizes

    • Test tubes showing fat and sugar in selected food items

    • Food label poster

    • web site

  1. Referrals

  1. All clients are referred to contact their primary health care provider within one week to discuss screening results, further recommendations, and rescreening interval.

  2. Additional referrals to primary medical provider may be made prn for ex. elevated blood pressure, hospital dietary consultation referral, health related complaints, suspected medical problems etc…

  1. Record Maintenance

A. Staple all forms together

B. File alphabetically by year of screening

C. Store in a locked filing cabinet for 7 years

D. Enter client data into screening computer program.

  1. Evaluation

  1. Follow-up conversations with repeat clients

  2. Client comments to RD, PHN, PH aide throughout screening visit

  3. Client self-reports by telephone call, drop-in visits etc… to RD, PHN, PH aide after screening

  4. Periodic surveys, Cholesterol/Diabetes Program Evaluation, mailed to clients

  5. Computer generated reports from screening computer program

Cholestech LDX Procedure Manual

Cholestech LDX User Manual

National Heart, Lung, and Blood Institute, National Institutes of Health (1995).

Recommendations Regarding Public Screening for Measuring Blood Cholesterol

(NIH Publ. No. 95-3045). Bethesda, MD.

The American Diabetes Association (2002). Position Statement: Screening for Diabetes.

Diabetes Care, 25, S21-S24. (Found at

National Cholesterol Education Program (2001). Expert Panel on Detection, Evaluation,

and 4. Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)

Executive Summary (NIH Pub. No. 01-3670). Bethesda, MD.

POLICY TITLE: Cholestech: Optics Check

EFFECTIVE DATE: 07/16/2012


AUTHORIZED BY: Jen Rombalski, Health Officer
To check the optical system of the Cholestech LDX Analyzer.
Public Health Nurse


  1. Verify that the Optics Check Cassette is not expired, damaged, or altered in any way. If so, discard the cassette and obtain a new one.

  2. Press the run button on the Analyzer. After verifying the “selftest OK” message, the drawer will open, and the screen will display: Load cassette and press RUN.
  3. Place the Optics Check Cassette into the cassette drawer. Do not place any blood sample on the cassette.

  4. Press the RUN button again and the Analyzer will automatically perform the Optics Check. The words Optics Check and four numbers will appear on the screen, one for each optical channel in the analyzer.

  5. If the numbers for all four channels fall within the ranges printed on the Optics Check Cassette label, the system is ready for use.

  6. If the numbers for any of the four channels fall outside the ranges printed on the optics check cassette label the analyzer will shut down. The analyzer will be disabled until another optics check has been run that falls within range. Try running an optics check with a different Optics Check Cassette. If the numbers are still outside the range, call Cholestech Technical Service at (800) 733-0404.

  7. Record the results and any action taken in the Optics Check Log.

Cholestech LDX Procedure Manual

Cholestech LDX User Manual

POLICY TITLE: Cholestech: Quality Control Testing

EFFECTIVE DATE: 07/16/2012


AUTHORIZED BY: Jen Rombalski, Health Officer
To verify that the Cholestech LDX System is working properly and giving dependable results.
Public Health Nurse

  1. Remove one vial each of Cholestech LDX Control Level 1 and Level 2 from the refrigerator.

  2. Note date opened on vial labels. Opened vials are stable for only 30 days. After 30 days, discard in biohazard waste container.
  3. Verify expiration date of controls. If expired, discard in the biohazard waste container.

  4. Warm Control Level 1 and Level 2 vials to room temperature (10 min.)

  5. Refer to the Cholestech LDX control Material Assay Sheet accompanying this product for information regarding the appropriate setting for sample type in the Cholestech LDX configuration Menu. If you need to change the sample setting, see the Cholestech LDX user Manual Section “Setting the configuration Menu”.

  6. Mix each vial by gently inverting 7-8 times.

  7. Unscrew the vial cap. Use the Mini-Pet pipette and tips provided in the Cholestech LDX Starter Pack to dispense the control material onto a test cassette. Follow the procedure directions for the test cassette being used. The controls are to be tested in the same manner as a client’s sample would be tested. Use a new tip for each control level.

  8. After use, wipe the top of the vial and replace the cap.

  9. Compare the results obtained for the controls with the assigned values given on the assay sheet, accompanying the package insert, to determine if the procedure is within control limits. (Be sure the lot number on the vial of control corresponds to the lot number on the Assay Sheet.)

  10. If the values are outside the Expected Range do the following:

  • Check the expiration date on control vial. Discard if outdated.

  • Review control product package insert and the operating procedure for the Cholestech LDX and test cassette, then run another control test on the same vial of control solution.

  • If the values are still outside the Expected Range, run another control test from a new vial of control solution.

  • If the values are still outside the Expected Range, call Cholestech Corporation Technical Service Department at (800) 733-0404.
  1. Return control solutions to the refrigerator. Controls are to be stored upright and refrigerated at 2-8C (36-46F). DO NOT FREEZE.

Cholestech LDX Procedure Manual

Cholestech LDX User Manual

POLICY TITLE: Public Health Clinic

EFFECTIVE DATE: 07/20/2012


AUTHORIZED BY: Jen Rombalski, Health Officer
To provide scheduled and unscheduled clinical services on a weekly basis for residents of the Buffalo County Health and Human Services jurisdiction. The most common services provided are physician ordered medication set up and injections, blood pressure checks, adult and childhood immunizations, and mantoux tests.



  1. Admission

  1. Initial Intake from Informed Referral Network

Referrals will be received from the following sources: physicians, other health care providers, social workers, other Health and Human Services staff, the client, or family members.

  • The Initial Contact Form (ICF) (Appendix-A) will be completed by the staff receiving the referral and will include the service requested.

  • The ICF will be routed to the Public Health Supervisor for staff assignment. All viable options for medication set-up or obtaining of injections will be reviewed prior to assignment.

  • The Public Health Supervisor will route the ICF to the appropriate staff to open the case.

  • Once the case is opened, the ICF will be returned to the PHN assigned to the case to follow-up and file in the client’s chart.

  1. Initial Client Contact to Schedule a Clinic Appointment

The PHN will contact the client by telephone or mail to schedule the initial clinic visit and obtain the name of the client’s primary physician and pharmacy. The client will be informed that they must bring all prescription medication or injection bottles to their initial clinic appointment. If medication boxes are to be filled at the first appointment, the PHN will need to obtain a signed Consent to Release Confidential Information (Appendix-B). The PHN will then obtain a list of medications from the primary physician and obtain all medication refills needed to complete the medication boxes for the time-period designated from the client’s pharmacy prior to the appointment. The PHN may also need to collect insurance information to provide to the pharmacy if the client has no record at that pharmacy.

  1. Physician Orders for Medications and Clinic Services

A signed physician order is required for all client medications including over-the-counter medications. See section 2 above.

  • The medical order must include the medication name, dose, frequency of clinic visits and physician preference for procedure when there is a medication change between clinic visits, route of administration as well as the physician signature and date the order was written.

  • The following are acceptable ways to obtain or receive a medication order:

    • Telephone order form (the order may be implemented prior to obtaining physician signature if the PHC primary PHN took the telephone order from the physician directly and the form is mailed to the physician for signature)

    • Fax with written or electronic signatures

    • Mail with written or electronic signatures

    • Order slip from the client (the slip must have a recognizable physician signature and the clinic name on it)
  • When a telephone order is received, the PHN will document the order on the Buffalo County Department of Health and Human Services Physician’s Telephone Orders form (Appendix-C). The PHN will place one duplicate copy of the telephone order in the client’s chart and mail the original copy to the physician for signature. Upon receipt of the signed order form, the duplicate in the chart will be replaced by the original, signed copy. The primary pharmacist will be notified of the medication order.

  • When obtaining a medication list from a physician as the medication order, the list must include a physician signature and date.

  • Medications changes cannot be made in the client’s medication box(es) without either a signed order or the PHN who is setting up the medication box(es) taking a direct verbal/telephone order and the order form has been sent to the physician for signature.

  • Physician’s order should include the frequency of visits to the PH Clinic (i.e. every 2 weeks to obtain medication boxes)

  1. Obtaining Medications From The Pharmacy Once Ordered

The following options are acceptable for obtaining medications for each client:

  • The client or other designated representative of the client such as a family member or volunteer driver can bring medications (prescription bottles or injection vials) to the clinic.

  • The pharmacy can mail medications to the PHC.

  • The PHN can retrieve medications directly from the pharmacy (pick up medications).

  1. Medication List

All medications for each client will be recorded on a medication list in the client record (see Appendix-D).

  • Each medication order or change will be documented on the medication list. Medications will be categorized under one of the following headings on the medication list: scheduled medications, PRN medications, medications taken at home (RN not responsible for set-up/management).

  • The medication list will serve as the quick reference document for the most up-to-date information on what medications the client is taking on a scheduled or as needed basis. New medications will be written into the appropriate area of the medication list as prescribed by the physician. Medication changes will be documented on the medication list as follows:

    • The old order will be highlighted in yellow. A single black line will be drawn through the order. The PHN will document the physician who discontinued the order and the date it was discontinued.

    • The new order will be written as prescribed by the physician on the next open line of the medication list.

  • After each medication is transcribed onto the list, the PHN will write “noted” with his/her initials next to the original physician order to document that the order has been transcribed into the medication list.

  1. The Initial Visit

The following steps will be taken at the initial client visit to the PHC:

  • The PHN will introduce his/herself to the client, explain the purpose of the PHC (purpose stated beneath “Medication Set-Up and Injections”), and provide an overview of PHC services available to the client. The PHN will discuss client expectations and responsibilities and provide client with the client responsibility sheet.

  • The PHN will complete the Patient Information Sheet (Appendix-E).

    • One person besides the client (ie-family member) must be identified to serve as a responsible party to the client’s care if necessary. A responsible party is defined as either 1. A Power of Attorney or Legal Guardian; 2. Someone willing to take on responsibility for client’s care regarding medications or medical needs; 3. Once a responsible party/emergency contact person is identified, the PHN will contact this person to explain the purpose of the PHC and what their responsibilities are. Mail a responsibililty sheet to responsible person.
    • The PHN will also document other public health or social services the client is receiving (ie-social worker or economic support worker) on the Patient Information Sheet. When the client requires case management, these duties will be referred to either the social worker or the responsible party listed on the Patient Information Sheet.

  • The PHN will obtain Consent to Release Confidential Information for each primary physician/clinic and the responsible party identified on the Patient Information Sheet.

  • The PHN will hand out the “Notice of Privacy Practices Regarding Health Information” brochure and obtain a signature on the “Acknowledgement of Receipt of Notice of Privacy Practices Regarding Health Information.” (Appendix-F)

  • The PHN will perform a baseline assessment. The assessment will be documented on the “Initial Assessment Form” and should include the following components to be used as a baseline for future reference:

    • Description of general health

    • Psychosocial status

    • Vital Signs (blood pressure, pulse, and respirations)

    • Weight

  • If physician orders were obtained prior to the initial visit, the PHN will discuss the following with the client regarding each physician-ordered medication.

    • What the pill(s) looks like

    • Why they are taking each medication

    • Side effects

    • Frequency and route of administration

The PHN will determine and document the client’s understanding of this information on the clinic visit flow sheet.

  • The PHN will dispense the filled medication box(es) or administer the injection to the client and discuss when the next appointment should be scheduled (this will be based on court order, the physician’s order or recommendation, or the PHN’s assessment). If physician orders were not obtained prior to the initial visit, this step will occur as follow-up to the initial visit once the orders have been obtained.

  1. Procedure for Administering Injections
  • The most common injections to the PHC are Haldol, Prolixin, and B12.

    • Haldol: use a 20-21 guage needle and administer it deep IM

    • Prolixin: use a 20-21 guage needle and administer it IM or SQ

    • B12: use a 20-25 guage needle and administer it IM

  1. Follow-Up to the Initial Visit

  • Once a signed Consent to Release Confidential Information form is obtained, the PHN will request medical records as appropriate from the client’s primary clinic(s). Once these records are received the PHN will review the records and file in the client’s chart.

  • In the event that signed physician orders were not received prior to the initial visit, the PHN will obtain physician orders as soon as possible and fill the medication box(es) according to these orders. The PHN will inform the client when the medication orders have been received and medications have been set-up in the medication box(es). The client will then be responsible to schedule an appointment to discuss each medication as described above and receive their medication box(es).

  1. Subsequent PHC Visits

  • The following options will be considered standard procedure for medication set-up for individual clients:

  1. The PHN will fill one or two medication boxes for the client. This will provide the client with one or two weeks of medication. The appointments should be scheduled every one or two weeks as appropriate. The PHN will determine the frequency of visits based on court order, the physician’s orders/recommendations, or his/her own assessment of the client’s medication compliance and needs.
  2. The medication box(es) will be filled one or two days prior to the clinic visit and will be stored in a locked medication cabinet in the clinic. The medication box(es) will be labeled with the client’s name and will be stored in an area of the cabinet clearly marked with the client’s name. Medications may also be filled at the visit with or without the client’s assistance.

  • A flow sheet (Appendix-H) will be used as documentation at each clinic visit. The flow sheet will document medication compliance, dispensing of medications, administration as appropriate for injections, side effects, changes in health since the previous visit, vital signs as appropriate, previous and upcoming physician appointments, and the date of the next PHC visit. Communications or events that occur between visits will be documented on the most recent flow sheet in the progress notes.

  • After assessment the PHN will report changes from baseline or abnormal findings to the primary or appropriate physician by phone, fax, or mail. Non-compliance with medications will be reported to the primary or appropriate physician on the first occurrence, at which time the PHN will compose a letter explaining the non-compliance and requesting information on what level of non-compliance is reportable to the physician for the individual client. The client, social worker, or emergency contact will be responsible for any follow-up with the physician.

  • At the end of each clinic day or clinic appointment, the PHN will document on the PHC Log located in the Clinic filing cabinet.

  • On an annual basis the following will be completed:

    • Review the Patient Information Sheet and responsible party designee

    • Have client sign new Consent to Release Information for all appropriate parties/facilities

    • Redistribute Privacy brochure and obtain signature that brochure was given out

    • Send medication list to each prescribing physician for signature

    • Renew order for PHC service frequency and medication box change for orders received between clinic visits.

  1. Maintenance of the Medication List & Dispensing Medications

  • The medication list will be maintained (see “Medication List” section for more information) in the following manner:

    • A copy of the new medication order may be faxed to the pharmacy, and the PHN will contact the pharmacy to obtain the new medication if necessary.

    • The medication list will be faxed or mailed to each medication-prescribing physician for each client for approval and signature minimally every 12 months. This may be done more often as needed or as desired by the PHN for clarification when medication changes are frequent, or by the clinic/physician for an updated list of the client’s current medications being set-up.

    • If a medication is discontinued, the prescription bottle will be labeled “discontinued” with date and PHN’s initials. The prescription bottle will be kept in the locked medication cabinet for one year and then discarded. If the medication is restarted within that year and the order is a match to the discontinued medication, the medication may be used for the new order with the physician’s permission.

  • Medication Dispensing and Maintenance:

    • Following each individual client PHC visit, the PHN will phone refill requests to the client’s pharmacy so that the medication refills can be obtained and the medication box(es) filled prior to the next PHC visit for that client. For medications that indicate no refills remain, the pharmacy will be responsible for faxing or phoning refill requests to the medical provider/clinic and will communicate the need for assistance from the PHN as necessary.

  • Whenever medications are changed or added, the client will be educated on the following:

    • What the pill(s) looks like

    • Why they are taking each medication
    • Side effects

    • Frequency and route of administration

  1. Attendance Policy

  • Clients will be expected to attend the PHC according to the doctor’s orders for attendance frequency. Clients attending the PHC for medication set-up in medication boxes will be encouraged to come to the clinic as scheduled. However, if the client must miss a clinic appointment, the client or PHN should make every effort to initiate a telephone interview to complete the flow sheet. The PHN will notify the doctor, and based on the physician’s recommendations, the medications will be dispensed. If a client is consistently disregarding this policy after education is given, all appropriate parties (ie-MD, Social Worker) will be notified and the situation will be handled on a case-by-case basis. Need for continuation of services will be assessed.

  1. Other Circumstances

  • The PHN shall be notified of any admission to or discharge from a skilled medical care facility (ie-hospital, nursing home). With client consent the PHN will fax the most recent medication list on request to the provider/clinic or hospital. In addition, the PHN will work with the social worker, physician, and client to coordinate the resuming of PHC services following discharge. This will include obtaining information on any and all medication changes while hospitalized and obtaining a physician’s order to resume PHC services. The client will be responsible for scheduling an appointment with the PHN to resume services and receive their medications. The client must also make arrangements with the discharging facility to have enough medications until the next PHC appointment.
  • The PHN shall be notified of any expected absence from participation in the PHC services (ie-vacation) no later than at the appointment immediately preceding the intended absence and preferably before this. The PHN will obtain direction from the physician as to dispensing of the medication(s) via a telephone order.

  • In the event that the PHC falls on a holiday or if the PHN is unavailable to perform the clinic services, the clinic will be rescheduled in advance to either a day prior or a day following the original date of the clinic. All regularly scheduled clients will be notified of the change. Medications will be set-up to assure that no doses are missed.

  • Standing Orders: Once a standing order is obtained from a physician it is not necessary to renew it (ie-“Medication Changes Received After the Clinic Visit”).

  • Medication boxes will be cleaned and relabeled PRN, between clients, and minimally once per year.

  1. Blood Pressure Checks

  • All requests for blood pressures checks on non-clinic days will be referred to either a clinic day or to the Public Health Supervisor as an intake. If the blood pressure check is viewed as an emergency, the client should be referred to their medical doctor or to call 911. See the policy/procedure pertaining to this walk-in clinical service.

  1. Adult and Childhood Immunizations

  • Requests for immunizations will be referred to the PHC, Immunization clinic, or to the Public Health Supervisor as an intake. See the policy/procedure pertaining to this walk-in clinical service.

  1. Mantoux Tests

  • See the policy/procedure pertaining to Mantoux Testing found in the Tuberculosis procedure.

  1. Discharge

  • Discharge planning will begin and be discussed at the initial intake visit. The PHN should research and present to the client all other options available to meet the client’s needs.

  • The client may be discharged from PHC services for any of the following reasons:
    • The service is no longer needed (ie- the client’s condition has improved and he/she is able to administer and manage medications without the PHC services)

    • Court order for medication set-up and/or injection has been fulfilled and the client demonstrates the ability to administer and manage medications properly without PHC services.

    • The client has moved to another jurisdiction.

    • The client’s health has declined to the point PHC services are no longer appropriate or similar services are being provided at a hospital/nursing home facility.

    • The client receives services from a different source (ie- a pharmacy mails the medications to the client).

    • The client has expired.

  • Once the client is discharged, the following steps will be taken:

  • The client will be officially notified of discharge by mail. A copy of the letter will be filed in the client’s chart. The letter should include information on how the client can obtain their remaining medications.

  • The physician will be notified by mail that client has been discharged from services and the reason for discharge. The date and reason for discharge will be documented on the client’s most recent flow sheet.

  • The chart will be routed to the appropriate agency staff to close the case and file the record.

  • All of the client’s medications that remain unclaimed after 30 days will be discarded.


POLICY TITLE: Wisconsin Well Woman Program (WWWP)



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer /Director

To assure availability of WWWP services to residents of Pepin County; to assure WWWP activities and services are carried out in accordance with established program policies and procedures.

Pepin County Health Department acts as the coordinating agency for WWWP. In carrying out activities related to WWWP, health department staff will follow the policies and procedures outlined in the Wisconsin Well Woman Program Policy and Procedures Manual found at:

Local coordinating agency responsibilities are described in chapter 2 of the manual, as well as in other locations throughout the document.

Because the Wisconsin Division of Public Health (DPH) has created a Wisconsin Well Woman Policy and Procedures Manual, this local agency policy will simply highlight certain portions of that manual and reflect specific local information and data. Health Department staff, including the designated WWWP coordinator, will utilize the established DPH policies and procedures for all program operations.
Essential Treatment Plan: The essential treatment plan is maintained in a separate folder in the WWWP coordinator’s office. Components of the plan are outlined in Chapter 2 of the Wisconsin Well Women Policy and Procedure Manual.
Outreach, Recruitment, and Education: The designated local WWWP coordinator will be a public health nurse. This individual will be in charge of outreach, recruitment, and education activities aimed at enrolling, screening, and re-screening women who are eligible for the program. This will be accomplished through a targeted marketing approach that includes:

  • Use of community assessment data

  • A variety of outreach strategies, such as the media, attending local health fairs, poster/flier distribution, small group presentations, displays, and contact of individuals
  • Encouraging local health care p

  • Providers and the human services agency to identify and refer potentially eligible women in their patient population

  • Utilizing promotional materials developed by DPH

Client Enrollment Process: The WWWP coordinator will assure that all women enrolled in WWWP meet the eligibility criteria. This includes: women age 45-64 who have no health insurance, or insurance doesn’t cover screenings, or the woman is unable to pay the high deductibles and co-payments; and the income is at or below 250% of the federal poverty level.
In order to enroll in WWWP, the client must:

  1. Live in Wisconsin

  2. Provide proof of age (birth certificate, driver’s license)

  3. Provide proof of income (pay stub, tax forms). A woman without a documented income may use eligibility for other social service programs, such as food stamps, WIC, or unemployment insurance, as proof of eligibility. When no form of documentation is available, the woman may sign a statement of income.

  4. Provide information about her insurance status.

  5. Complete and sign the WWWP enrollment form found here:

S:\PUBLIC HEALTH\WWWP\Forms-Letters\WWWP Enrollment Form.pdf
Women must re-enroll in WWWP annually, so the local coordinator will maintain a tracking system to determine when women are due to re-enroll in the program. Enrollment forms will automatically be sent to women who are due. This reminder system will also include a tickler to allow the coordinator to alert women when they are due for screenings.
For women who are due for screenings and re-enrollment, the enrollment form will be sent along with the re-screening reminder letter and instructions.

Covered services: WWWP covers screening services for: breast cancer, cervical cancer, and staged assessment for multiple sclerosis. However, all medical services related to these areas may not be covered. See the WWWP Screening Guidelines and Covered Services document attached to the DPH policy manual for a complete listing of covered services.

Wisconsin Well Women Medicaid (WWWMA)

WWWMA provides Medicaid coverage for certain women who have been diagnosed with and who need treatment for breast cancer, cervical cancer, or a precancerous cervical lesion and who are eligibile for WWWP. Chapter 7 and Appendix 9 of the WWWP Policy and Procedures Manual give specific details on client eligitbility for WWWMA as well as the WWP coordinator’s role in assisting with client enrollment in WWWMA and completing the WWWMA Determination Form (F-10075), available at:

Forms: It is important that when a woman goes to the health care provider for services she has the appropriate WWWP forms along with her. The following forms are necessary:
For breast cancer or cervical cancer screening:

  • A copy of the completed enrollment form

  • Breast and Cervical Cancer Screening Activity Report (ARF) found here:

If cervical cancer screening was abnormal and the woman is returning for follow-up:

  • A copy of the completed enrollment form

  • Cervical Cancer Diagnostic and Follow-up Report (DRF) found here:

S:\PUBLIC HEALTH\WWWP\Forms-Letters\WWWP DRF cervical.pdf
If breast cancer screening was abnormal and the woman is returning for follow-up:

  • A copy of the completed enrollment form

  • Breast Cancer Diagnostic and Follow-up Report (DRF) found here:

S:\PUBLIC HEALTH\WWWP\Forms-Letters\WWWP DRF breast.pdf


Client demographics, date of enrollment, date of initial screenings, and dates of re-screening and diagnosis are entered into an agency database. The number of Pepin County women ages 35-64 years old who received screening services through WWWP will be determined at the end of each calendar year to determine if the agency met the Consolidated Contract Grant objective set forth by the Wisconsin Division of Public Health. The priority population for mammography services is women ages 50-64; a minimum of 75% of all mammograms should be provided to women in this age group. The priority for cervical cancer screening services is women between the ages of 35-64 who have never been screened or have not been screened in the past five years. 20% of all cervical cancer screenings should be provided to women in this age group.

Client demographics, date of enrollment, date of initial screenings, and dates of re-screening and diagnosis are entered into an agency data base. The number of Pepin County women ages 35-64 years old who received screening services through WWWP will be determined at the end of each calendar year to determine if the agency met the Consolidated Contract Grant objective set forth by the Wisconsin Division of Public Health. The priority population for mammography services is women ages 50-64; a minimum of 75% of all mammograms should be provided to women in this age group. The priority for cervical cancer screening services is women between the ages of 35-64 who have never been screened or have not been screened in the past five years. 20% of all cervical cancer screenings should be provided to women in this age group.



  • Wisconsin State Statute 255.06 Well Woman Program

POLICY TITLE: Communicable Disease Investigation and Control



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director

1. To assure early detection of, and effective response to communicable disease.

2. To reduce incidence of communicable diseases including food borne, waterborne, and vaccine preventable diseases.

3. To provide epidemiological follow-up on all reportable communicable disease

4. To provide education on communicable disease prevention to individuals and the community.

5. To observe and report trends on communicable disease.

6. To recognize when a communicable disease event rises to the level of a public health emergency and triggers the Public Health Emergency Plan (PHEP).

In collaboration with the Communicable Disease Section of the Wisconsin Division of Public

Health, Pepin County Health Department executes the requirements described in Chapter 252

Wisconsin Statutes regarding the reporting, surveillance, and control of communicable diseases.

These responsibilities are accomplished through the cooperative efforts of hospital infection

control personnel, health care providers, local health departments, and the Wisconsin State

Laboratory of Hygiene.

Pepin County Health Department encompasses both passive disease surveillance (from provider reports) and active disease surveillance (initiating contact to search for possible cases). Pepin County Health Department maintains a surveillance system that is compatible with the statewide system, including:

  • Maintaining a supply of current communicable disease report forms (DOH 44151);

  • Supporting training of staff to accurately and efficiently use of the Wisconsin Electronic Disease Surveillance System ( WEDSS);

  • Receiving, evaluating, data entering, and transmitting completed reports to the state epidemiologist via paper or the preferred method of WEDSS;

  • Investigating each communicable disease reported to gather epidemiologic and laboratory data for local, state, and national surveillance;

  • Conducting a detailed follow-up as noted in the Control of Communicable Diseases Manual, current edition, to prevent future cases, identify the etiologic agent, and identify the mode of transmission;

  • Consulting with the state epidemiologist or other Division of Public Health staff whenever any unusual circumstances occur or to help answer questions;
  • Implementing control measures for specific diseases consistent with measures recommended by the state epidemiologist;

  • Consulting with the Health Officer to determine when an outbreak rises to the level of a public health emergency requiring activation of the Public Health Emergency Plan (PHEP). Activation of the PHEP should be considered when:

    • The situation is urgent in nature.

    • Staff’s daily work must be redirected to address the situation.

    • An interdisciplinary response is needed (environmental health, health educators, nurses, etc.).

    • The response will last more than one day.

Disease Outbreaks or Clusters

  1. Alert the Health Officer to situations involving an unusual number of cases of a particular illness occurring in a given timeframe or geographical location.

  2. Verify the diagnoses of individuals affected by the outbreak and establish the actual existence of the outbreak or epidemic.

  3. Contact the Wisconsin Division of Public Health, Regional Western Office to advise them of the situation. The regional office will inform the central office in Madison of the outbreak. The Division of Public Health will then offer guidance regarding what steps to take next, what lab specimens to collect, what forms to complete, etc.

  4. In consultation with the management team, determine whether the Public Health Emergency Plan (PHEP) should be activated. Keep in mind the triggers listed above.

  5. Contact local health care providers to inform them of the outbreak situation.

  6. Follow the instructions of the Division of Public Health in implementing control measures. Collect and submit lab specimens as directed and as authorized by the Pepin County Health Department Public Health Program Standing Orders.

  7. Prepare and submit an outbreak investigation report in collaboration with the Division of Public Health.
  8. The cost of the investigation is the responsibility of the Pepin County Health Department. The Division of Public Health will assume the costs of having their staff on site, if needed.

  9. Activate the Public Health Emergency Plan when instructed by the Health Officer.

  10. Contact the Western Wisconsin Consortium to update them and request assistance, if necessary.

Single Case Communicable Disease Follow-Up

  1. Upon diagnosis of a reportable communicable disease (see back of DOH 44151 for a complete list of reportable diseases), the clinic/lab/provider will complete the DOH 44151 and send it to Pepin County Health Department or complete the information in WEDSS and submit it electronically to the Pepin County Health Department.

  2. The DOH 44151 will be given to the Health Officer for review. Case follow-up will be delegated to a public health nurse (PHN). If received electronically the director or designated local WEDSS system administrator will assign the case to a PHN.

  3. If the lab/clinic/provider calls with a report and does not send a DOH 44151, health department staff will enter the data into WEDSS. Category I suspect or diagnosed reportable diseases and conditions must be reported by the lab/clinic/provider immediately by phone or in person. Category I case report forms must be submitted by mail or electronically within 24 hours.

  4. Using the EPINET and Control of Communicable Diseases Manual, the nurse will read the information available about the particular disease and complete any additional required forms. If additional paper forms are required, they will be found in the EPINET. The required forms for each disease incident are already formatted into WEDSS and can be filled out electronically.

  5. After gathering this information, the nurse will call the affected individual or parent/guardian. Any information still needed to complete required forms will be obtained at this time.
  6. The nurse will contact the individual as soon as possible following receipt of the report of illness. The individual will be instructed regarding treatment, prevention and the potential source of the infection. Any questions the individual may have will be addressed. It is often helpful to send the client a copy of the Wisconsin DHFS communicable disease fact sheet for the specific disease.

  7. If the nurse is unable to reach the client by phone, contact will be initiated via mail. If the client does not respond after two written letters to the client, all paperwork will be submitted to the Division of Public Health Communicable Disease section and the case will be closed. Several attempts will also be made via phone calls at different times of the day.

  8. If unable to submit data electronically via the WEDSS Reporter, paperwork will be submitted via mail to the address below or by fax to the Bureau of Communicable Disease individual program fax number (“CONFIDENTIAL” will be typed on the envelope/fax face sheet):

Wisconsin Division of Public Health

Communicable Disease Section

1 West Wilson Street, Room 318

Madison, WI 53702

FAX: (608)-261-4976

  1. If Pepin County Health Department receives a higher than usual number of reports for a given disease, enhanced surveillance will be initiated to determine if the cases are related.

  2. In accordance with Wisconsin Statute 252.05(11), any violation of communicable disease reporting by physicians or other health care providers will be reported to the Pepin County District Attorney’s Office.

11) Department of Health 44151 and other paper documentation will be stored for 7 years following date of report,after which records will be destroyed by shredding. Reports received and completed electronically via the Wisconsin Electronic Disease Surveillance System (WEDSS) will be stored through the Public Health Information Network (PHIN) and their policies. If the 44151 and other paper documentation are electronically scanned into WEDSS, it does not need to be stored at the department.

Quarterly and annual statistics of reported diseases will be reviewed, analyzed, and provided to the Health and Human Services Committee. Program will be assessed annually for necessary procedural changes.


  • Control of Communicable Diseases Manual (current edition)

  • Red Book (current edition)

  • EpiNet Manual, State of Wisconsin, Department of Health and Family Services, EpiNet guidelines can be found under “Information for Health Professionals” on each disease page listed at the Communicable Disease Subject A-Z Index at:

  • Packaging Clinical Laboratory Samples for Domestic Transport (current guidelines)

  • WEDSS Reporter: Wisconsin

  • Administrative Code Chapter 145

  • Chapter 252 Wisconsin Statutes

POLICY TITLE: Infection Control and Prevention



AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
To assure prompt, complete, and uniform follow-up of all incidents involving exposure to blood, body fluids, and other potentially infectious materials. To facilitate recommended testing of individuals involved in such incidents and allow for proper medical management and if necessary, treatment.

Pepin County Health Department employees will be assured prompt and complete follow-up of blood/body fluid exposures. Guidelines recommended by the Centers for Disease Control and Prevention (CDC) for the prevention of the spread of HIV, Hepatitis B, and Hepatitis C will be followed when conducting follow-up of exposure to blood and/or body fluids. CDC publications guide the health department director in providing this follow-up and assure all necessary steps are taken for the protection of the exposed individual.

An exposure that might place an employee at risk for Hepatitis B, Hepatitis C, or HIV infection is defined as a percutaneous injury (e.g., a needle stick or cut with a sharp object) or contact of mucous membrane or non-intact skin (e.g., exposed skin that is chapped, abraded, or afflicted with dermatitis) with blood, tissue, or other body fluids that are potentially infectious.
Any exposure to blood, body fluids, or other potentially infectious material will be immediately reported to the health department director. Evaluation of each exposure incident shall be consistent with the Exposure Control Plan, using the Employee Bloodborne Incident Report. The incident report can be found here: S:\PUBLIC HEALTH\Updated Policies and Procedures 2012\Communicable Disease\Blood and Body Fluid Policy Forms\Bloodbborne Incident Report.doc. The health department director or his/her designee, along with the Safety Department Director will assist the exposed individual in setting up an appointment with a health care provider within 24 hours. The health department director will assure that current CDC recommendations are followed.
The following are recommendations for follow-up. The health care provider seen by the exposed individual will be responsible for ordering and administering medications/treatment. The health care provider is required to provide a written opinion regarding testing and prophylaxis within 14 days.

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