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TUBERCULOSISSKINTESTFORM

Healthcare Professional/Patient Name:

Testing Location:

 

 

 

 

 

 

 

 

 

 

 

Date Placed:

 

 

 

 

 

 

 

 

 

 

 

 

Site:

Right

Left

 

 

 

 

 

 

 

 

Lot #:

 

 

 

 

 

Expiration Date:

 

 

Signature (administered by):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RN

 

MD Other:

 

 

 

Date Read (within 48-72 hours from date placed):

 

 

 

 

 

 

Induration (please note in mm):

 

mm

PPD (Mantoux) Test Result:

 

 

 

Negative

Positive

Signature (results read/reported by):

RN

MD Other:

*In order for this document to be valid/acceptable, all sections of this form must be completed.

Document Information

Fact Name Details
Purpose of the Form The Tuberculosis Skin Test Form is used to document the administration and results of the TB skin test.
Required Information All sections of the form must be completed for it to be valid and acceptable.
Healthcare Professional The form must include the name of the healthcare professional administering the test.
Testing Location The location where the test is administered must be clearly stated on the form.
Date Placed The date when the test is administered is a crucial part of the documentation.
Induration Measurement The size of the induration must be recorded in millimeters (mm).
Test Result The result of the PPD (Mantoux) test can be either negative or positive.
Governing Laws State-specific laws may govern the use of TB test forms; for example, some states require specific documentation under public health regulations.

Tb Test - Usage Guidelines

After obtaining the TB Test form, you will need to provide specific information related to the test. This form must be filled out completely to ensure its validity. Follow the steps below to accurately complete the TB Test form.

  1. Healthcare Professional/Patient Name: Write the full name of the healthcare professional administering the test or the patient receiving the test.
  2. Testing Location: Indicate the location where the test is being administered.
  3. Date Placed: Enter the date on which the test is placed.
  4. Site: Mark whether the test was placed on the right or left side of the body.
  5. Lot #: Fill in the lot number of the PPD used for the test.
  6. Expiration Date: Write the expiration date of the PPD test material.
  7. Signature (administered by): The administering healthcare professional should sign here. Indicate their title (RN, MD, or Other).
  8. Date Read: Record the date when the test results are read, which should be within 48-72 hours from the date placed.
  9. Induration: Measure and note the induration in millimeters (mm).
  10. PPD (Mantoux) Test Result: Mark the result as either Negative or Positive.
  11. Signature (results read/reported by): The healthcare professional reading the results should sign here and indicate their title (RN, MD, or Other).

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Dos and Don'ts

When filling out the TB Test form, there are important steps to follow. Here are some guidelines to help ensure that the form is completed correctly.

  • Do fill in all required sections of the form completely.
  • Do double-check the dates to ensure accuracy.
  • Don't leave any fields blank; incomplete forms may not be accepted.
  • Don't forget to sign the form where indicated.

Common mistakes

  1. Incomplete Information: One common mistake is not filling out all required sections of the form. Every field, including the healthcare professional's name and testing location, must be completed for the document to be valid.

  2. Incorrect Induration Measurement: When measuring the induration, it is crucial to record the measurement in millimeters accurately. Failing to do so can lead to incorrect interpretations of the test results.

  3. Missing Signature: The form requires signatures from both the person administering the test and the one reading the results. Omitting these signatures can render the form unacceptable.

  4. Ignoring Expiration Dates: The lot number and expiration date of the PPD solution must be noted. Using expired materials can affect the test's reliability and lead to invalid results.

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