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Chief Complaint
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History Of Present Illness
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Travel / Exposure History
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Has the patient traveled anywhere outside of {{INSERT YOUR STATE}} in the last 30 days?
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Where?
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Has the patient traveled to China, Iran, Italy, Japan, or South Korea in the last 14 days?
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Where?
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Airline Carrier
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Flight Number
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Seat Number
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In the 14 days prior to illness onset, did the patient have any of the following exposures?
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Comments
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Johns Hopkins COV-19 Interactive Map:
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https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6
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CDC Travel Health Notices List:
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https://www.cdc.gov/coronavirus/2019-ncov/travelers/
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Criteria to Guide Evaluation of PUI for COVID-19:
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https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html
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FIRST Criteria for Person Under Investigation MET IF:
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Patient has fever (either subjective or confirmed)
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OR patient has signs/symptoms of lower respiratory illness
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AND any close contact** with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset
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Does patient have a fever?
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Comments
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OR
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Does patient have any of the following signs/symptoms of lower respiratory illness?
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Comments
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AND
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Any close contact** with a laboratory-confirmed COVID-19 patient within 14 days of symptom onset?
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** Per CDC, close contact is defined as:
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a) being within approximately 6 feet (2 meters) of a COVID-19 case for a prolonged period of time
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close contact can occur while caring for, living with, visiting, or sharing a healthcare waiting area or room w/ a COVID-19 case
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– or –
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b) having direct contact with infectious secretions of a COVID-19 case (e.g., being coughed on)
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If such contact occurs while not wearing recommended personal protective equipment or PPE
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(e.g., gowns, gloves, NIOSH-certified disposable N95 respirator, eye protection),
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criteria for PUI consideration are met.
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US Guidance for Risk Assessment/Public Health MNGT of Healthcare Personnel w/ Potential Exposure to COVID-19 Patients:
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https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-risk-assesment-hcp.html
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SECOND Criteria for Person Under Investigation MET IF:
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Patient has a fever (either subjective or confirmed)
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AND patient exhibits signs/symptoms of lower respiratory illness requiring hospitalization
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AND has a hx of travel from affected geographic areas (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
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Does patient have a fever?
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Comments
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AND
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Does patient have any of the following signs/symptoms of lower respiratory illness requiring hospitalization?
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Comments
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AND
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Any history of travel from affected geographic areas** (China, Iran, Italy, Japan, South Korea) within 14 days of symptom onset
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Comments
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** Per CDC, affected geographic areas are defined as
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geographic regions where sustained community transmission has been identified.
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Relevant affected areas will be defined as a country with at least a CDC Level 2 Travel Health Notice.
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CDC Travel Health Notices List:
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https://www.cdc.gov/coronavirus/2019-ncov/travelers/
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THIRD Criteria for Person Under Investigation MET IF:
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Patient has a fever with severe acute lower respiratory illness requiring hospitalization & without alternative etiology
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AND No source of exposure has been identified
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Does patient have a fever w/ severe acute lower respiratory illness requiring hospitalization & w/o alternative etiology?
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Comments
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AND
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Any identifiable source of exposure?
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Comments
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Review of Symptoms
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Fever > 100.4F (38C)
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Comments
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Subjective fever (felt feverish)
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Comments
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Chills
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Comments
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Myalgia
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Comments
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Rhinorrhea
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Comments
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Sore throat
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Comments
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Cough (new onset)
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Comments
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Cough (worsening of chronic cough)
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Comments
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Dyspnea
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Comments
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Nausea or vomiting
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Comments
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Headache
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Comments
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Abdominal pain
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Comments
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Diarrhea (>= 3 loose / looser than normal stool / 24 hour period)
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Comments
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Other symptoms
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Pre-existing Medical Conditions
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Asthma
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Comments
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Emphysema
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Comments
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COPD
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Comments
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Diabetes Mellitus
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Comments
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Cardiovascular disease
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Comments
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Chronic Renal disease
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Comments
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Chronic Liver disease
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Comments
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Immunocompromised condition
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If yes, specify
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Neurologic /neurodevelopment / intellectual disability
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If yes, specify
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Other chronic illness
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If yes, specify
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If female, currently pregnant
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Comments
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Social History
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Current smoker
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Comments
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Former smoker
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Comments
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Vaping
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Comments
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Result
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Does patient meet Person Under Investigation Criteria?
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Comments
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If a patient is classified/suspected as a PUI for COVID-19,
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IMMEDIATELY notify infection control personnel at your facility and your state or local health department
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Disposition of Patient
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Comments
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Patient education given and Patient (if laboratory-confirmed sick with COVID-19 or under investigation) advised to
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Created 03/2020
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