A TB skin test (Mantoux tuberculin skin test or PPD test) screens for Mycobacterium tuberculosis infection. This test involves injecting a small amount of tuberculin purified protein derivative (PPD) under the skin. Accurate documentation is fundamental for patient care, public health tracking, and compliance with medical and legal standards.
Key Data Points for Documentation
Documenting a TB skin test requires specific details for accuracy and traceability. Patient identification (full name, date of birth, unique identifier) is recorded. The date and time of PPD administration must be noted.
Information about the tuberculin solution includes its lot number, expiration date, and manufacturer. The injection site and amount of PPD administered must be specified.
The name, title, and signature of the administering healthcare professional are documented. When the test is read (usually 48 to 72 hours post-administration), the date, time, and reader’s name, title, and signature are recorded.
Induration measurement, recorded in millimeters (mm), is a key data point. Erythema (redness) may be present but is not measured; only its presence or absence is noted.
Interpreting and Recording Test Results
Properly reading a TB skin test involves distinguishing between induration and erythema. Induration refers to a palpable, raised, and hardened area at the injection site, while erythema is merely redness. Only the induration is measured to determine the test result.
To measure induration, a ruler is used to find the widest diameter of the raised, hardened area across the forearm. The measurement should be recorded precisely in millimeters. The final interpretation of the result depends on this measurement and the patient’s individual risk factors.
Different induration cut-offs are used to classify results as positive or negative. For instance, an induration of 5 mm or more may be considered positive for individuals with weakened immune systems or recent contact with someone with active TB. For healthcare workers or people from areas where TB is common, 10 mm or more might indicate a positive result. A measurement of 15 mm or more is generally considered positive for individuals with no known risk factors for TB.
The specific measurement must be documented, such as “12 mm induration, no erythema,” followed by the final interpretation, like “Positive” or “Negative.” This detailed recording provides a clear record of the test outcome.
Best Practices for Accurate Documentation
Ensuring accuracy in documentation involves adhering to several best practices. All handwritten records should be legible to prevent misinterpretation. Utilizing official forms, standardized charts, or electronic health records (EHRs) helps maintain consistency and completeness in documentation.
Every entry must be dated and signed by the individual making the record. If an error occurs, it should be corrected by drawing a single line through the incorrect information, writing the correct details, and then initialing and dating the correction. White-out or similar methods should never be used, as they obscure the original entry.
Ambiguous abbreviations should be avoided to prevent confusion and ensure clarity. It is also important that documentation is contemporaneous, meaning it is recorded at the time the event or observation occurs. These practices support the integrity and reliability of the medical record.
Post-Documentation Procedures
Once the TB skin test results are meticulously documented, several subsequent steps are typically initiated. Timely communication of the results to the patient and any relevant healthcare providers is an important next step. This ensures that the patient is informed and that their care team is aware of the outcome.
For positive test results, further diagnostic testing is often necessary. This may involve a chest X-ray to check for active lung disease or sputum cultures to confirm the presence of Mycobacterium tuberculosis. Consideration for treatment of latent TB infection might also be discussed to prevent the development of active disease.
Additionally, positive TB cases often require reporting to local or state public health departments. This reporting helps in tracking disease prevalence and implementing public health control measures. Accurate documentation plays a significant role in facilitating these follow-up actions and maintaining continuity of care for the patient.