Diagnostic Bronchoscopy by zbk75252


									                         Diagnostic Bronchoscopy

   Per Case Recommendation on Personal Protective Equipment

                      For Staff in Bronchoscopy Suite

(To be completed by physician doing diagnostic bronchoscopy within the 24
hours of preceding the procedure.)

   1) How likely does this patient have tuberculosis disease
      involving the respiratory tract? (Please check one.)

      ____________                ____________           __________
         not likely                   possible               likely

   2) Should staff in the bronchoscopy suite wear personal
      protective equipment (fit-tested N95 respirators or powered
      air-purifying respirators) to protect themselves against
      airborne tuberculosis transmission during the upcoming
      procedure on ___________________? (Please check one.)
                             name of patient

                           ____                  ____
                            yes                   no

      _________________________                         _____________
        signature of physician                            date signed

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