Master List of HCH Forms Currently Barcoded and - Department of ...
Master List of HCH Forms Currently Barcoded and - Department of ...
Master List of HCH Forms Currently Barcoded and - Department of ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
EFFECTIVE REVISON<br />
FORM NO. FORM NAME<br />
DATE DATE DEPT OF ORIGIN<br />
<strong>HCH</strong>-1439 1:1 Constant Observation Daily Observation Plan/H<strong>and</strong> Off Communication Form Dec-01 Jul-09 Nursing<br />
<strong>HCH</strong>-1430 1:1 Constant Observation Order Sheet Feb-06 Oct-11 Nursing<br />
<strong>HCH</strong>-600 15 Minute Checklist Replaced by <strong>HCH</strong>2287 Jun-06 Sep-10 Psychiatry<br />
<strong>HCH</strong>-600A 15 Minute Checklist Psychiatric Geriatric Medicine (Psych) Replaced by <strong>HCH</strong>2287 Jun-06 Apr-07<br />
Wm. White, MD / Lorraine<br />
<strong>HCH</strong>-1872 24 Hour Ambulatory Blood Pressure Monitor Request Jul-07 Nov-07 Iverson<br />
<strong>HCH</strong>-2062 30 Minute Checklist - Psychiatric Geriatric Medicine<br />
<strong>HCH</strong>-2061 30 Minute Checklist - Psychiatric Unit<br />
<strong>HCH</strong>-1361A A Sibling Visitation Screening for Infection Control-Spanish Jul-03 Feb.-06<br />
<strong>HCH</strong>-2352 AACU CORE Interdisciplinary Database Apr-12 Jessie Riemer<br />
<strong>HCH</strong>-1053 AACU Orders for ERCP Sept.-97<br />
<strong>HCH</strong>-2039 Abatacept (Orencia) After-Care Instructions (Rheum Infusion)<br />
<strong>HCH</strong>-2032 Abatacept (Orencia) Infusion Record (Rheum Infusion)<br />
<strong>HCH</strong>-2035 Abatacept (Orencia) Pre-Infusion Assessment Checklist (Rheum Infusion)<br />
<strong>HCH</strong>-2054 Abatacept (Orencia) Pre-Printed Order Set<br />
<strong>HCH</strong>-1749 Abatacept Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2241 Abnormal Involuntary Movement Scale (AIMS) Mar-10 J. Lounsbury<br />
<strong>HCH</strong>-1354 Accounting Log for Disclosure PHI 50 or more Research Subjects Apr-03 I. Mauriello-Compliance<br />
<strong>HCH</strong>-1989 Accutane/Soriatane Flowsheet (UMG)<br />
<strong>HCH</strong>-1341 Acute Coronary Syndrome - Inpatient Order Sheet Sept.-02 May-07 Cardiology<br />
<strong>HCH</strong>-2259 Acute Hemodialysis Flowsheet Jun-10<br />
<strong>HCH</strong>-2358 Acyclovir - Oral Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1843 Add On requisition (Lab Medicine) For UMG <strong>and</strong> JDH<br />
<strong>HCH</strong>-1773 ADL Scale - Evaluation (UMG) Geriatrics Nov-06 Carol Clynes-Geriatrics<br />
<strong>HCH</strong>-971 Administration <strong>of</strong> Medication - Internal Review Hearing Sep-95 Aug-10 J. Lounsbury<br />
<strong>HCH</strong>-1035 Admission Orders Uncomplicated Term Labor Jun-97 Jan.-98<br />
<strong>HCH</strong>-1034 Admission Orders-Stroke Care Path1 Mar-97 Apr-06<br />
<strong>HCH</strong>-2175 Admitting Orders for Scheduled C-Section Sep-09 OB/GYN G. Muscillo<br />
<strong>HCH</strong>-1844 Adult Immunization Visit (Division <strong>of</strong> Infectious Disease) GI/ID<br />
<strong>HCH</strong>-1322 Adult Inpatient Immunization Screening Form Jan.-01 Mar-11 Nancy Dupont<br />
<strong>HCH</strong>-2285 Adult Parenteral Nutrition Fluid Orders - Individualized Formulas Nov-10 Jan-11 Pharmacy<br />
<strong>HCH</strong>-1737 Adult Patient Bipap System Check Record Nov-06 Oct-10 UMG<br />
<strong>HCH</strong>-993 Adult Patient Ventilator System Check Record<br />
<strong>HCH</strong>-561 Advance Directive Form Feb-91 Aug-11 Admitting/Carlene Bartolotta<br />
<strong>HCH</strong>-2336 Advanced Cardiac Imaging (CT <strong>and</strong> MRI) Request Form Dec-11 Feb-12 Linda Manzelli<br />
<strong>HCH</strong>-368 Against Medical Advice Feb.-77 Apr-06 I.Mauriello-Compliance<br />
<strong>HCH</strong>-368A Against Medical Advice UMG Jun-06 UMG<br />
<strong>HCH</strong>-1746 Agalsidase beta Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2235 Alcohol Withdrawal Prevention Clinical Institute Withdrawal Assessement (CIWA Mar-10 Mar-11 Am<strong>and</strong>a Darcey<br />
<strong>HCH</strong>-1748 Alglucosidase alfa Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-1473 Allergy Continuation <strong>of</strong> Care Letter Jun-06 E.Wagner<br />
<strong>HCH</strong>-1762 Allergy Flow Sheet Treatment Set #1 Dec-06 May-08 E.Wagner<br />
<strong>HCH</strong>-1761 Allergy Flow Sheet Treatment Set #2 Dec-06 May-08 E.Wagner<br />
<strong>HCH</strong>-1536 Allergy Individual Dose Flow Sheet UMG Nov-06 Apr-10 Elissa Wagner<br />
<strong>HCH</strong>-1490 Allergy Vials Consent Form UMG Jul-06 E.Wagner<br />
<strong>HCH</strong>-2000 Alopecia Follow Up Encounter (UMG Derm)<br />
<strong>HCH</strong>-1751 Alpha-Proteinase Inhibitor Infusion Orders Dec-06 Dec-10 Jessie Riemer<br />
8/3/2012 - 9:53 AM 1/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1826 Altered Health Nursing Care Plan (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-1826A Altered Health Nursing Care Plan Addendum (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-1772 Alternative Therapies Questionnaire (UMG) Dec-06 Ute Schroeder<br />
<strong>HCH</strong>-1515 Ambulatory Summary <strong>List</strong> Oct.-06 May-10 Ann Marie Capo<br />
<strong>HCH</strong>-2357 Ambulatory Summary <strong>List</strong> - Cancer Center Jun-12 Jul-12 Jessie Riemer/Georg'Ann Bona<br />
<strong>HCH</strong>-2350 Ambulatory Summary <strong>List</strong>: Pulmonary Apr-12 Georg'Ann Bona<br />
<strong>HCH</strong>-1819 Ambulatory Surgery Discharge Instructions (Farmington Surgery Center)<br />
<strong>HCH</strong>-1259 Ambulatory Surgery Pre-Op H&P Orders Feb.-99<br />
<strong>HCH</strong>-1371 Amniocentesis Dec.-03 Nov-11 Nursing<br />
<strong>HCH</strong>-1847 An Important Message from Medicare About Your Rights Aug-11 Cathy Cruz (Case Mgmt)<br />
<strong>HCH</strong>-1847S An Important Message from Medicare About Your Rights (Spanish version) Aug-11 Cathy Cruz (Case Mgmt)<br />
<strong>HCH</strong>-765 Anatomic Pathology Specimen Requisition Apr-93 Aug.-07 Pathology<br />
<strong>HCH</strong>-1159 Anemia Transfusion <strong>of</strong> Packed Red Blood Cells Jan.-98 Sept.-00<br />
<strong>HCH</strong>-675 Anesthesia Record - Order from warehouse (Moore) Anesthesiology<br />
<strong>HCH</strong>-774 Anesthesiology Orders: Adult Perianesthesia Care Jul-93 Jul-12 OR Carol Schramm<br />
<strong>HCH</strong>-1188 Anesthesiology Orders: Adult Perianesthesia - CARS Jul-93 Jan-12 Carol Schramm<br />
<strong>HCH</strong>-2330 Anesthesiology Orders: Adult Perianesthesia - ECT Nov-11 Carol Schramm<br />
<strong>HCH</strong>-774P Anesthesiology Orders For Pediatric Post-Anesthesia Care Unit (Replaced by <strong>HCH</strong>-2011) May-01 May-06<br />
<strong>HCH</strong>-2011 Anesthesiology Orders: Pediatric Perianesthesia Care Jan-08 Jun-11 Carol Schramm<br />
<strong>HCH</strong>-1343 Anesthesiology Pre Admission Questionnaire Nov.-02 Nov.-04 Anesthesiology<br />
<strong>HCH</strong>-1548 Animal Care Contact Questionnaire OCC Med Emp Health Dec-06 S. Barnosky - Occ Med<br />
<strong>HCH</strong>-1419 Ankle Evaluation Rehab Oct-05 Rehab<br />
<strong>HCH</strong>-2309 Annual Comprehensive Diabetes Foot Exam Jun-11 Georg'Ann Bona<br />
<strong>HCH</strong>-583 Antepartum Flowsheet (OB/GYN) Dec.-91 Jan-10 Nursing<br />
<strong>HCH</strong>-1803 Antepartum Record (UMG OB/GYN)<br />
<strong>HCH</strong>-1174 Antepartum Testing - Non Stress Test (UMG OB/GYN) Mar-98 Mar-07 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-1410 Antepartum testing for Multiple Gestation May-05 MFICU<br />
<strong>HCH</strong>-1378 ANTEPARTUM TESTING FOR SINGLETONS Jul-02 Feb.-05<br />
<strong>HCH</strong>-1744 Antibiotics InfusionPre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
Anuja Durman/Anticoagulation<br />
<strong>HCH</strong>-1835 Anticoagulation Protocol/Collaborative Practice Agreement Jun-07 Jan-12 Clinic<br />
<strong>HCH</strong>-1811 Anticoagulation Service Encounter Note (Anticoag Clinic)<br />
<strong>HCH</strong>-1810 Anticoagulation Service Referral (Anticoag Clinic)<br />
<strong>HCH</strong>-1813 Anticoagulation Service Teaching Flow Sheet (Anticoag Clinic)<br />
<strong>HCH</strong>-1812 Anticoagulation Service Warfarin Dose Monitoring Flow Sheet (Anticoag Clinic)<br />
<strong>HCH</strong>-625 Apnea/Bradycardia Flowsheet Feb.-1992 Sep-11 Nursing<br />
<strong>HCH</strong>-2320 APRV Mechanical Ventilation Flowsheet Oct-11 Janet Schoenewolff<br />
<strong>HCH</strong>-1868 Aquatic Progress Note (Rehab) Jul-07 Apr-10 B. Boucher<br />
<strong>HCH</strong>-1655 Asbestos Patient Questionnaire (OCC MED) Nov-96 Nov-06<br />
<strong>HCH</strong>-1023 Asbestos Questionnaire Jan.-97<br />
<strong>HCH</strong>-1205 Asthma Acute Exacerbation Admission Orders Jun-98<br />
<strong>HCH</strong>-1206 Asthma Care Path Jun-98<br />
<strong>HCH</strong>-1204 Asthma Discharge Discharge Orders Jun-98<br />
<strong>HCH</strong>-1541 Audiogram UMG Nov-06 May-12 Elissa Wagner / Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-1404 Authorization for Cystic Fibrosis Screening Apr-05<br />
<strong>HCH</strong>-2077 NO LONGER A CHART FORM Authorization for Hypothermia Treatment (NICU) DEACTIVATED 10/2011<br />
<strong>HCH</strong>-127A Authorization forTransfusion <strong>of</strong> Blood or Blood Products Apr-79 Oct.-09<br />
8/3/2012 - 9:53 AM 2/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-127 Authorization for Medical Surgical Procedure Apr-79 Feb-11 Carol Schramm<br />
<strong>HCH</strong>-1366 Authorization for Medical Surgical Procedure Aug-03<br />
<strong>HCH</strong>-1356 Authorization for Medical Surgical Procedure UFE May-03 Feb.-06<br />
<strong>HCH</strong>-1357 Authorization for Medical Surgical Procedure VK May-03 Feb.-06<br />
<strong>HCH</strong>-12724 Authorization for Medical/Surgical Procedure 24hr pH Study<br />
<strong>HCH</strong>-12723 Authorization for Medical/Surgical Procedure 24hr pH Study w/Impedance<br />
<strong>HCH</strong>-12747 Authorization for Medical/Surgical Procedure A-1 Release Mar-10 Sep-10 K. Clarke<br />
<strong>HCH</strong>-12752 Authorization for Medical/Surgical Procedure: Adenotonsillectomy Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12713 Authorization for Medical/Surgical Procedure Allergy Testing (UMG)<br />
<strong>HCH</strong>-12702 Authorization for Medical/Surgical Procedure Amniocentisis<br />
<strong>HCH</strong>-12739 Authorization for Medical/Surgical Procedure Bronchoscopy<br />
<strong>HCH</strong>-12746 Authorization for Medical/Surgical Procedure Carpel Tunnel Mar-10 Sep-10 K. Clarke<br />
<strong>HCH</strong>-12701 Authorization for Medical/Surgical Procedure Chorionic Villus Sampling<br />
<strong>HCH</strong>-12728 Authorization for Medical/Surgical Procedure Circumcision<br />
<strong>HCH</strong>-12748 Authorization for Medical/Surgical Procedure CMC Arthroplasty May-10 K. Clarke<br />
<strong>HCH</strong>-12725 Authorization for Medical/Surgical Procedure Colonoscopy/Upper Endoscopy<br />
<strong>HCH</strong>-12704 Authorization for Medical/Surgical Procedure Colposcopy<br />
<strong>HCH</strong>-12744 Authorization for Medical/Surgical Procedure- Coronary Balloon Angioplasty or Stenting Feb.-10 K.Coyne<br />
<strong>HCH</strong>-12705 Authorization for Medical/Surgical Procedure Cryotherapy<br />
<strong>HCH</strong>-12734 Authorization for Medical/Surgical Procedure Direct Laryngoscopy<br />
<strong>HCH</strong>-12749 Authorization for Medical/Surgical Procedure Distal Radius<br />
<strong>HCH</strong>-12710 Authorization for Medical/Surgical Procedure Elective Repeat C-Section<br />
<strong>HCH</strong>-12708 Authorization for Medical/Surgical Procedure Endometrial Biopsy<br />
<strong>HCH</strong>-12733 Authorization for Medical/Surgical Procedure Endoscopic Sinus Surgery<br />
<strong>HCH</strong>-2185 Authorization for Medical/Surgical Procedure Epidural Steroid Injection Oct-09<br />
<strong>HCH</strong>-12727 Authorization for Medical/Surgical Procedure ERCP<br />
<strong>HCH</strong>-12719 Authorization for Medical/Surgical Procedure Esophageal Manometry<br />
<strong>HCH</strong>-12720 Authorization for Medical/Surgical Procedure Flexible Sigmoidoscopy<br />
<strong>HCH</strong>-12745 Authorization for Medical/Surgical Procedure Foot & Ankle Mar-10 K. Clarke<br />
<strong>HCH</strong>-12753 Authorization for Medical/Surgical Procedure: Hemithyroidectomy Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12714 Authorization for Medical/Surgical Procedure ICD Implantation<br />
<strong>HCH</strong>-12707 Authorization for Medical/Surgical Procedure Insertion <strong>of</strong> IUD<br />
<strong>HCH</strong>-12706 Authorization for Medical/Surgical Procedure LEEP<br />
<strong>HCH</strong>-12726 Authorization for Medical/Surgical Procedure Liver Biopsy Dec-06 Nov-09<br />
<strong>HCH</strong>-12750 Authorization for Medical/Surgical Procedure Mass Excision Oct-10 Kelly Clarke<br />
<strong>HCH</strong>-12731 Authorization for Medical/Surgical Procedure Moh's Micrographic Surgery<br />
<strong>HCH</strong>-12754 Authorization for Medical/Surgical Procedure: Myringtomy with tube Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12758 Authorization for Medical/Surgical Procedure: Nerve Decompression St<strong>and</strong>ard Consent Jan-12 Kelly Clarke<br />
<strong>HCH</strong>-12743 Authorization for Medical/Surgical Procedure-Orthopaedic Surgery Apr-79 Nov.-09 K.Clarke<br />
<strong>HCH</strong>-12730 Authorization for Medical/Surgical Procedure Paracentesis<br />
<strong>HCH</strong>-12721 Authorization for Medical/Surgical Procedure Perc Endoscopic Gastrostomy<br />
<strong>HCH</strong>-12741 Authorization for Medical/Surgical Procedure Peripheral Artery Angiography & Intervention<br />
<strong>HCH</strong>-2186 Authorization for Medical/Surgical Procedure Peripherally Inserted Central Cath (PICC) Oct-09 Oct-10<br />
<strong>HCH</strong>-12715 Authorization for Medical/Surgical Procedure Permanent Pacemaker<br />
<strong>HCH</strong>-12742 Authorization for Medical/Surgical Procedure Physiatry Nov.-09<br />
<strong>HCH</strong>-12722 Authorization for Medical/Surgical Procedure Pill Enteroscopy<br />
8/3/2012 - 9:53 AM 3/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-12740 Authorization for Medical/Surgical Procedure Renal Artery Angiography & Intervention<br />
<strong>HCH</strong>-12729 Authorization for Medical/Surgical Procedure Sonohysterogram<br />
<strong>HCH</strong>-12735 Authorization for Medical/Surgical Procedure Stereotactic Biopsy <strong>of</strong> Breast Clip<br />
<strong>HCH</strong>-12751 Authorization for Medical/Surgical Procedure Thumb Carpometacarpal Arthroplasty Oct-10<br />
<strong>HCH</strong>-12755 Authorization for Medical/Surgical Procedure: Tonsillectomy Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12736 Authorization for Medical/Surgical Procedure Total Hip<br />
<strong>HCH</strong>-12737 Authorization for Medical/Surgical Procedure Total Knee<br />
<strong>HCH</strong>-12756 Authorization for Medical/Surgical Procedure: Total Thyroidectomy Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12757 Authorization for Medical/Surgical Procedure: Transnasal Esophagoscopy Nov-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-12703 Authorization for Medical/Surgical Procedure Tubal Ligation<br />
<strong>HCH</strong>-12712 Authorization for Medical/Surgical Procedure Vagal Nerve Stim Implant<br />
<strong>HCH</strong>-12716 Authorization for Medical/Surgical Procedure: Electrophysiology Study/Ablation<br />
<strong>HCH</strong>-1342 Authorization for MedicalSurgical Procedure-Pill Enteroscopy Oct.-02 Feb.-06 Gastroenterology<br />
<strong>HCH</strong>-2124 NO LONGER A CHART FORM Authorization for Transfusion <strong>of</strong> Blood or Blood Products - NICU DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1770 Authorization to Obtain <strong>and</strong> Release Pathology Slides/Reports Jan-07 Pathology<br />
<strong>HCH</strong>-1369 Authorization to Obtain <strong>and</strong>/or Disclose Health Information - Research Jul-10 Jul-03<br />
<strong>HCH</strong>-551 Authorization to Obtain or Disclose Health Information Jul-03 Aug-11 Medical Records-E.Albini<br />
<strong>HCH</strong>-962 Automatic Stop Orders-Pre-Percutaneous Coronary Angioplasty Mar-95 Apr-06 Cardiology<br />
<strong>HCH</strong>-1561 Back Pain Questionnaire OCC Med Employee Health Dec-06<br />
<strong>HCH</strong>-1611 Batch Cover Sheet Feb-09 Aug-11 HIM<br />
<strong>HCH</strong>-1627 Batch Cover Sheet Nov-06<br />
<strong>HCH</strong>-1914 Beck Depression Inventory (Sleep Disorders Center)<br />
<strong>HCH</strong>-1861 Beck Inventory (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-1313 Beck Inventory Item #9 Jan.-00 Psych. Nursing<br />
<strong>HCH</strong>-894 Bedside Swallow Evaluation Jul-94 Aug.-06<br />
<strong>HCH</strong>-1915 Bedtime Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-591 Behavioral Health Restraint/Seclusion Flow Sheet Replaced by <strong>HCH</strong>-2287 May-91 Mar-09 Nursing<br />
<strong>HCH</strong>-1975 Biologic Medication Monitoring Flowsheet (UMG)<br />
<strong>HCH</strong>-1142 Bipolar Disorder Carepath Manic Episode<br />
<strong>HCH</strong>-1895 Birthing Room Newborn Flow Sheet (Labor <strong>and</strong> Delivery) 00-05 Sep-10<br />
<strong>HCH</strong>-1240 Blood <strong>and</strong> Blood Components Transfusion Order Sheet Sept.-98 Mar-10<br />
<strong>HCH</strong>-2021 Blood Bank Emergency Blood Request (Blood Bank)<br />
<strong>HCH</strong>-1262 Blood Bank Requisition Nov-98 Oct-10<br />
<strong>HCH</strong>-1754 Blood Component Transfusion Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-762 Blood Gas Analysis Requisition Apr-93 Oct-10 Resp. Care<br />
<strong>HCH</strong>-1048 Boarder Newborn - Deleted Jul-97 Sept.-00<br />
<strong>HCH</strong>-1951 Body MR Questionnaire (Diagnositc Imaging) Oct-07 Aug-10 Radiology<br />
<strong>HCH</strong>-1782 Botox Cosmetic Consent (JDH Dermatology) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-1528 Botulinum Toxin Data Sheet UMG Nov-06<br />
<strong>HCH</strong>-1253 Patient <strong>and</strong> Family Teaching Record - Bowel Resection Feb.-99 Dec.-00<br />
<strong>HCH</strong>-1949 Brain Questionnaire (Diagnostic Imaging) Oct-07 Aug-10 Radiology<br />
<strong>HCH</strong>-1689 Breast Diagram (Cancer Center)<br />
Martha Hein-Neag Cancer<br />
<strong>HCH</strong>-1769 Breast Follow Up Encounter (Cancer Center) 00-05 Nov-06 Center<br />
<strong>HCH</strong>-2238 Breast History Reference Guide Mar-10 Lori Wilson<br />
8/3/2012 - 9:53 AM 4/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1688 Breast Lump New Encounter Note (Cancer Center)<br />
<strong>HCH</strong>-1178 Breast Milk Inventory Apr-98 Sep-11<br />
<strong>HCH</strong>-1952 Breast Questionnaire (Diagnostic Imaging) Oct-07 Aug-10 Radiology<br />
<strong>HCH</strong>-1396 Breastfeeding Discharge Checklist Aug-04 Elaine Gerry<br />
<strong>HCH</strong>-1061 Breastfeeding <strong>and</strong> Breast Pumping - No longer using 3/09<br />
<strong>HCH</strong>-1063 NO LONGER A CHART FORM Bronchopulmonary Dysplasia DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1499 Bronchoscopy Discharge Instructions Sep-06 N.Mclellan-Pulmonary Lab<br />
<strong>HCH</strong>-1399 Bronchoscopy Report Final Oct.-05 Mar-06 C.Schramm<br />
<strong>HCH</strong>-1256 Patient <strong>and</strong> Family Teaching Record - CABG-Valve Replacement Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1158 CAD Cardiac Catheterization Jan.-98 Sept.-00<br />
<strong>HCH</strong>-1411 Cancellation <strong>and</strong> No Shows Sep-05 Rehab<br />
<strong>HCH</strong>-1694 Cancer Center Database Apr-07 Dec-11 Jessie Riemer<br />
<strong>HCH</strong>-1046 Cancer Center Nursing Assessment (Cancer Center/Med Surg 5) Jun-97 Sept.-07 Donna Pryor<br />
<strong>HCH</strong>-2237 Cancer Center Skin <strong>and</strong> Wound Assessment Mar-10<br />
<strong>HCH</strong>-2242 Cancer Prevention Program Patient Database Mar-10 Ute Schroeder<br />
<strong>HCH</strong>-877 Cardiac Cath Care <strong>of</strong> Patient Post Procedure May-94 Sept.-96 Med Surgery<br />
<strong>HCH</strong>-2211 Cardiac Catheterization Discharge Instructions Ambulatory Patient Info.Femoral Approach Dec.-09 Nov-11 C.Ingriselli<br />
<strong>HCH</strong>-2210 Cardiac Catheterization Discharge Instructions Ambulatory Patient Info.-Radial Approach Dec.-09 Nov-11 C.Ingriselli<br />
<strong>HCH</strong>-2156 Cardiac Magnetic Resonance (CMR) Request (Radiology) Jun-09 Apr-10 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-1817 Cardiac Monitor Flow Sheet (Med-Surg) Apr-07 Oct-11 Debra Cratty<br />
<strong>HCH</strong>-1301 Cardiac Stepdown Nursing Unit Flowsheet Feb.-08 Nov-11 Julie Laflamme<br />
<strong>HCH</strong>-1408 Cardiology Established Patient Visit Apr-05 Dec-11 Dr. Liang/ K. Lundquist<br />
<strong>HCH</strong>-1409 Cardiology New Patient Visit Apr-05 Dec-11<br />
<strong>HCH</strong>-355 Cardiology Nuclear Medicine Consultation Requisition Dec.-74 Aug-10 L Manzelli-Cardiology<br />
<strong>HCH</strong>-2396 Cardiology Service Ultrafiltration: Additional Therapy Orders Jul-12 J. Laflamme<br />
<strong>HCH</strong>-2395 Cardiology Service Ultrafiltration: Initial Orders Jul-12 J. Laflamme<br />
<strong>HCH</strong>-1794 Cardioversion Discharge Instructions - Amb Pt Information Electrophysiology Mar-07 Cardiology<br />
<strong>HCH</strong>-1025 Care Path Community Acquired Pneumonia Feb.-97 Feb.-00<br />
<strong>HCH</strong>-1209 Care Path Delivery (Extended Stay) Addendum Sept.-98 Feb.-03<br />
<strong>HCH</strong>-1267 Care Path for Well Newborn Nov.-98 Aug-11 Elaine Gerry<br />
<strong>HCH</strong>-1214 Care Path Modified Radical Mastectomy Sept.-98 00-00<br />
<strong>HCH</strong>-1215 Care Path Stroke Sept.-98 00-00<br />
<strong>HCH</strong>-1796 Remote Transmission Not Received - Electrophysiology Mar-07 Dec-10 B. Johnson - Cardiology<br />
<strong>HCH</strong>-1446 Carotid Angioplasty Order Sheet Mar-06 P. Bozeman-Vascular Surgery<br />
<strong>HCH</strong>-1510 Cast Change Form Oct-06 Kelly Clarke<br />
<strong>HCH</strong>-2296 Cast Request/Change Form Feb-11 Kelly Clarke<br />
<strong>HCH</strong>-2312 Cathflo® (Alteplase) Order Form Jul-11 Jessie Riemer<br />
<strong>HCH</strong>-1990 Cellcept Flowsheet (Dermatology)<br />
<strong>HCH</strong>-2359 CellCept (Mycophenolate M<strong>of</strong>etil) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2110 Center for Joint Preservation <strong>and</strong> Replacement New Patient Questionnaire (Ortho)<br />
<strong>HCH</strong>-2234 Central/Arterial Line Insertion Procedure Note & Checklist Feb-10 Mar-10 Nancy Dupont<br />
<strong>HCH</strong>-1401 Cerebral Aneurysm Coiling Templated Form Feb-05 OR Nursing<br />
<strong>HCH</strong>-773 Certificate <strong>of</strong> Baptism May-04 Dec.-2005 Pastoral Services<br />
<strong>HCH</strong>-1418 CERVICAL EVALUATION Oct-05 Rehab<br />
<strong>HCH</strong>-1954 Cervical Thoracic Spine Questionnaire (Diagnostic Imaging) Oct-07 Aug-10 Radiology<br />
<strong>HCH</strong>-1208 Cesarean Delivery Care Path Sept.-98 Feb-10<br />
HCh-2322 Chemotherapy Drug Extravasation Documentation Form Oct-11 J. Riemer<br />
<strong>HCH</strong>-1022 Chemotherapy Orders Dec.-96 Dec.-99<br />
8/3/2012 - 9:53 AM 5/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1134 Chemotherapy Teaching Nov.-97 Sept.-00<br />
<strong>HCH</strong>-2086 Chemotherapy Treatment Plan (Cancer Center)<br />
<strong>HCH</strong>-2041 Child <strong>and</strong> Adolescent Outpatient Disharge Summary (Outpatient Psych)<br />
Geraldine Pearson/Judy<br />
Lounsbury<br />
Geraldine Pearson/Judy<br />
<strong>HCH</strong>-2042 Child <strong>and</strong> Adolescent Outpatient Medication Mgmt Progress Note (Outpt Psych) Apr-08 Mar-11 Lounsbury<br />
Geraldine Pearson/Judy<br />
<strong>HCH</strong>-2043 Child <strong>and</strong> Adolescent Outpatient Medication Mgmt Treatment Plan (Outpt Psych)<br />
Lounsbury<br />
Geraldine Pearson/Judy<br />
<strong>HCH</strong>-2040 Child <strong>and</strong> Adolescent Outpatient Progress Note (Outpatient Psych)<br />
Lounsbury<br />
Geraldine Pearson/Judy<br />
<strong>HCH</strong>-2044 Child <strong>and</strong> Adolescent Outpatient Psychotherapy Progress Note (Outpt Psych)<br />
Lounsbury<br />
Geraldine Pearson/Judy<br />
<strong>HCH</strong>-2045 Child <strong>and</strong> Adolescent Outpatient Psychotherapy Treatment Plan (Outpt Psych)<br />
Lounsbury<br />
<strong>HCH</strong>-1916 Children's Sleep Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-1554 Clearance Letter - Animal Contact OCC Med Employee Health Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1551 Clearance Letter - Laser Eye OCC Med Emp Health Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1547 Clearance Letter - Pre Placement UMG OCC MED Emp Hlth Nov-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1559 Clearance Letter Respirator OCC Med Employee Health Nov-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1400 Clinic Pre-Op Teaching Record Nov-04 UMG<br />
<strong>HCH</strong>-129A Clinical Context Data for Autopsy Oct-06 Nursing<br />
<strong>HCH</strong>-2221 Clinical Global Impression Jan.-10 R. Viens<br />
<strong>HCH</strong>-135 Clinical Record May-69 Feb-06<br />
<strong>HCH</strong>-2049 Clinical Record - Observation Nurse's Note<br />
<strong>HCH</strong>-2050 Clinical Record - Restraints/Seclusion May-08 Jun-11 Am<strong>and</strong>a Darcey<br />
<strong>HCH</strong>-550 Clinical Resume - Order from warehouse (Moore) May-89 Oct.-03 Nursing<br />
<strong>HCH</strong>-2152 Clinical Resume W10 (NBN) Jul-09 Oct-11 Terry Donovan<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2301 Closed Wound Care Instructions May-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1509 Colon Cancer Prevention Program Discharge Instructions Oct-06 Melissa Parente<br />
<strong>HCH</strong>-1815 Colonoscopy/Endoscopy Direct Booking Request with H&P Exam (Procedure Ctr)<br />
<strong>HCH</strong>-2349 Common Toxicity Criteria - Adverse Events (CTC-AE) Scales (NCI 2010) Mar-12 Jessie Riemer<br />
<strong>HCH</strong>-1910 Communication Letter (Ob/GYN)<br />
<strong>HCH</strong>-1212 Community Acquired Pneumonia Clinical Pathway Sept.-98 00-00<br />
<strong>HCH</strong>-2344 Comprehensive Spine Surgery New Patient Questionnaire Jan-12 Kelly Clarke<br />
<strong>HCH</strong>-1448 Confusion Assessment Method (CAM) Apr-06 00-00 K. Susco-Psych. Nursing<br />
<strong>HCH</strong>-1800 Congestive Heart Failure Encounter Note - Cardiology Mar-07<br />
<strong>HCH</strong>-1318 Conscious Sedation/Analgesia Flow Sheet - Order from warehouse (Moore) Oct.-00 Nov-11<br />
<strong>HCH</strong>-2279 Consent for the Administration <strong>of</strong> Chemotherapy Nov-10 Oct-11 Jessie Riemer<br />
<strong>HCH</strong>-969 Consent for Administration <strong>of</strong> Medication Sept.-95 Apr-06<br />
<strong>HCH</strong>-1680 Consent for Cardiac Stress Test Using Persantine (Spanish)<br />
<strong>HCH</strong>-1679 Consent for Echocardiography Stress Test (Spanish)<br />
<strong>HCH</strong>-1309 Consent for Electroconvulsive Therapy Dec.-89 Apr-06 Psych-ECT<br />
<strong>HCH</strong>-1682 Consent for Exercise Stress Test (Spanish)<br />
<strong>HCH</strong>-1681 Consent for Nuclear Exercise (Spanish)<br />
<strong>HCH</strong>-1508 Consent for Prenatal Analysis <strong>of</strong> Amniotic Fluid Cells (FISH) Oct-06 Nancy Maxwell<br />
<strong>HCH</strong>-2091 Consent for Radiological Imaging During Pregnancy Apr-08 Oct-11 Andres Sinisterra<br />
<strong>HCH</strong>-1567 Consent for Screening <strong>and</strong>/or Immunization for Minors OCC Med Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-2140 Consent for Treatment - Rad Onc<br />
8/3/2012 - 9:53 AM 6/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1573 Consent to Photograph or Tape Voice/Vocal Cords UMG Nov-06<br />
<strong>HCH</strong>-375 Consent to Photograph, Film, Videotape <strong>and</strong> Audiotape Jul-93 Jul-09 I.Mauriello-Compliance<br />
<strong>HCH</strong>-1781 Consent to Pulsed Light Treatment (UMG Dermatology) Jan-07 Dermatology<br />
<strong>HCH</strong>-1307 Consent to Transfer Nov-99 Oct-10<br />
<strong>HCH</strong>-939 Consent to Transfer Acute Nov.-94 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-872 Consent to Transfer Child to Another Institution Feb.-94 Sep-11<br />
<strong>HCH</strong>-503 Consultation Report 00-2005 Mar-09<br />
<strong>HCH</strong>-11 Consultation Request UMG Jan-71 Feb.-2006 UMG<br />
<strong>HCH</strong>-1941 Continuity <strong>of</strong> Care Report (Psych)<br />
<strong>HCH</strong>-1738 Continuous Ventilator Record<br />
<strong>HCH</strong>-1113 COPD Acute Exacerbation Oct.-97 Dec.-00<br />
<strong>HCH</strong>-1281 CORE Interdisciplinary Database Feb.-99 Oct.-01<br />
<strong>HCH</strong>-1753 Corticosteroid Infusion Order Set Dec-06 Apr-12 Jessie Riemer<br />
<strong>HCH</strong>-2177 Cover Sheet Series Patients-HIM Use Only Sep-09 HIM Dept<br />
<strong>HCH</strong>-1036 CPR Report Jan.-86 Aug.-07<br />
<strong>HCH</strong>-1912 Crisis Assessment (Dept <strong>of</strong> Psychiatry) DEACTIVATED 5/2012 00-2005 Oct-11 J. Lounsbury<br />
<strong>HCH</strong>-2155 Critical Results Notification Form (Nursing)<br />
<strong>HCH</strong>-1452 CRRT Orders Apr-06 ICU<br />
<strong>HCH</strong>-2360 Cryotherapy <strong>and</strong> Curettage (C & C) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2361 Cryotherapy Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-610 CT Computerized Tomography Consultation Request - Order from warehouse (Moore) Dec.05 Nov-11 S.Hensel-Radiology<br />
<strong>HCH</strong>-2261 CT Questionnaire Jul-10 Nov-11 D. McMahon<br />
<strong>HCH</strong>-1562 Cumulative Audiometric Flow Sheet OCC Med Employee Health Nov-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1988 Cyclosporine Flowsheet (Dermatology)<br />
<strong>HCH</strong>-1581 Cytogenetic Test Request Form to Accompany Specimens Aug-00 Dec-06 Lisa Ramsdell/UMG Genetics<br />
<strong>HCH</strong>-1942 Daily Group Individual Progress Notes - Psych 1<br />
<strong>HCH</strong>-1477 Daily Group Progress Note OCCUPATIONAL THERAPY May-05 Jul-06<br />
<strong>HCH</strong>-1476 Daily Progress Group Note PSYCH GERIATRIC May-05 Oct-06<br />
<strong>HCH</strong>-1425 Daily Progress Note- Rehab Nov-05 May-10 B. Boucher-Rehab<br />
<strong>HCH</strong>-2311 Daily Treatment Record - HDR Brachytherapy Jul-11 A. Sinisterra/K. Stook<br />
<strong>HCH</strong>-2204 Daily Treatment Record-Tomotherapy Nov.-09 Jan-10 D. Litke<br />
<strong>HCH</strong>-2205 Daily Treatment Record-Unit Precise Nov.-09 D. Litke<br />
<strong>HCH</strong>-2362 Dapsone Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1961 Dapsone Flow Sheet (Derm)<br />
<strong>HCH</strong>-709 Database Inpatient Nov.-97 Jun-03 Physical Therapy<br />
<strong>HCH</strong>-1873 Deaf <strong>and</strong> Hard <strong>of</strong> Hearing Language Assessment (Social Work)<br />
<strong>HCH</strong>-1406 Decentralized Laboratory Testing Reference Ranges Replaced by <strong>HCH</strong>-2290 Apr-05 Dec-09 Darlene Benson<br />
<strong>HCH</strong>-1522 Decentralized Laboratory Testing Worksheet (UMG & JDH) Apr-05 Dec-09 Darlene Benson<br />
<strong>HCH</strong>-1924 Decision to Decline Prenatal Testing (Ob/GYN)<br />
<strong>HCH</strong>-1291 Deep Vein Thrombosis Oct.-98 Dec.-00<br />
M. Rathier-<br />
<strong>HCH</strong>-1445 DELIRIUM PROTOCOL ORDER Mar-06 Jan.-07 Med/Geriatrics/Psych<br />
<strong>HCH</strong>-1774 Depression Scale (UMG) Geriatrics Nov-01 Carol Clynes-Geriatrics<br />
<strong>HCH</strong>-1891 Dermatology Cosmetic Procedure Note (Dermatology)<br />
<strong>HCH</strong>-1610 Dermatology Encounter Note (JDH) Nov-06 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1783 Dermatology Intense Pulse Light Consultation Checklist (UMG Derm) Jan-07 Dermatology<br />
<strong>HCH</strong>-1890 Dermatology Operative Note (Dermatology) Jul-07 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1571 Dermatology Patient Questionnaire (JDH) Nov-06 Apr-11 Cathy Sonnenberg<br />
8/3/2012 - 9:53 AM 7/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1785 Dermatology Physician Correspondence (JDH Derm) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-1607 Dermatology Procedure Note UMG Oct-97 Nov-06<br />
<strong>HCH</strong>-1935 Dermatology Test Results (Derm)<br />
<strong>HCH</strong>-1604 Dermatopathology Patient Information Sheet (JDH) Jul-96 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1846 Detailed Notice <strong>of</strong> Discharge<br />
<strong>HCH</strong>-1867 Detoxification Flow Sheet CIWA-Ar/NAS<br />
<strong>HCH</strong>-2243 Detoxification Flow Sheet - NAS Apr-10 J. Lounsbury<br />
<strong>HCH</strong>-1827 Detoxification Nursing Treatment Plan (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-1795 Device Clinic Paceart Letter - Electrophysiology Mar-07 Cardiology<br />
<strong>HCH</strong>-1434 Device Interrogation Report Pacemaker Mar-07 Cardiology/Electrophysiology<br />
<strong>HCH</strong>-882 Diabetes Antepartum Visit<br />
Diabetes Assessment & Individual Instruction Summary (UMG)<br />
Jun-94 Apr-09 MFICU<br />
<strong>HCH</strong>-1620<br />
Diabetes Assessment /MPW Instruction Summary (UMG)<br />
Oct-97 Oct-06 C. Mensing- Diabetes Education<br />
<strong>HCH</strong>-1621<br />
Oct-07 Nov-06 C. Mensing- Diabetes Education<br />
<strong>HCH</strong>-1617 Diabetes Care Flow Sheet (UMG)<br />
Diabetes Educ Patient Referral/Order for Medication Initiation UMG<br />
Oct-97 Dec-06<br />
<strong>HCH</strong>-1622<br />
Feb-06 Nov-06 C. Mensing- Diabetes Education<br />
<strong>HCH</strong>-1623 Diabetes Education Referral/Order Form (UMG) Nov-98 Sep-06<br />
<strong>HCH</strong>-2347 Diabetes Follow-up Questionnaire Feb-12 Ute Schroeder<br />
<strong>HCH</strong>-1050 Diabetes in Pregnancy Aug.-97 Sept.-2000<br />
<strong>HCH</strong>-1888 Diabetes Management Questionnaire<br />
Diabetes Pump Program - Patient Instructions (UMG)<br />
<strong>HCH</strong>-1618<br />
Apr-06 Jan-07 C.Mensing- Diabetes Education<br />
<strong>HCH</strong>-576 Diagnostic Radiology Consultation Request - Order from warehouse (Moore) Dec.-05 Jun-06 D. Romano<br />
<strong>HCH</strong>-1877 Discharge from Electroconvulsive Therapy (ECT)<br />
<strong>HCH</strong>-1466 Dizziness Questionnaire Jan-01 May-06 E.Wagner<br />
<strong>HCH</strong>-913 Do Not Resuscitate <strong>and</strong> Comfort Measures Only Orders - Order from warehouse (Moore) Apr-95 Nov-11 Carol Schramm<br />
<strong>HCH</strong>-2304 Dobutamine Stress Echo Aortic Stenosis Protocol Orders May-11 Linda Manzelli<br />
<strong>HCH</strong>-2302 Dobutamine Stress Echo Ischemia Protocol Orders May-11 Linda Manzelli<br />
<strong>HCH</strong>-1512 Dobutamine Stress Echo Pre-Procedure Orders Oct-06 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-2303 Dobutamine Stress Echo Viability Protocol Orders May-11 Linda Manzelli<br />
<strong>HCH</strong>-2094 Documentation Clarification - Acute Renal Failure (HIM USE ONLY)<br />
<strong>HCH</strong>-2096 Documentation Clarification - Anemia (HIM USE ONLY)<br />
<strong>HCH</strong>-2098 Documentation Clarification - Blood Loss (HIM USE ONLY)<br />
<strong>HCH</strong>-2103 Documentation Clarification - CHF (HIM USE ONLY)<br />
<strong>HCH</strong>-2099 Documentation Clarification - COPD Exacerbation (HIM USE ONLY)<br />
<strong>HCH</strong>-2093 Documentation Clarification - Debridement (HIM USE ONLY)<br />
<strong>HCH</strong>-2095 Documentation Clarification - General (HIM USE ONLY)<br />
<strong>HCH</strong>-2100 Documentation Clarification - Malnutrition (HIM USE ONLY)<br />
<strong>HCH</strong>-2101 Documentation Clarification - Pneumonia (HIM USE ONLY)<br />
<strong>HCH</strong>-2102 Documentation Clarification - Sepsis (HIM USE ONLY)<br />
<strong>HCH</strong>-2097 Documentation Clarification - Stages <strong>of</strong> Chronic Kidney Disease (HIM USE ONLY)<br />
<strong>HCH</strong>-2276 Door to Balloon Time Sheet Oct-10 Cathy Ingriselli<br />
<strong>HCH</strong>-2363 Doxycycline Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1118 Dual Diagnosis Oct.-97 Sept.-00<br />
<strong>HCH</strong>-1138 DVT Teaching Nov.-97 Sept.-00<br />
<strong>HCH</strong>-2208 DXA Bone Density Consultation Requisition (Order from Warehouse - Moore Form) Dec.-09 Dec-11 S. Hensel<br />
8/3/2012 - 9:53 AM 8/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-2334 DXA Bone Density History Form Dec-11 Wendy Tolman-Andrews<br />
<strong>HCH</strong>-1374 Early Parenteral Nutrition Orders for Very Low Birth Weight Infants Feb.-04 Jul-09<br />
<strong>HCH</strong>-1943 ECT Cerebral Dominance Testing Protocol (Psych)<br />
<strong>HCH</strong>-1460 ECT Continuous Medication <strong>List</strong> Jan-05 May-06 K.Susco Nursing Psych<br />
<strong>HCH</strong>-1461 ECT Geriatric Depression Scale Jan-05 Jun-09<br />
<strong>HCH</strong>-1462 ECT Insurance Authorization Jan-05 May-06 K.Susco Nursing Psych<br />
<strong>HCH</strong>-1464 ECT Mini-Mental State Examination Jan-05 Jun-09<br />
<strong>HCH</strong>-1463 ECT Montgomery-Asberg Depression Rating Scale Jan-05 May-06 K.Susco Nursing Psych<br />
<strong>HCH</strong>-1863 ECT Referral Intake Screening<br />
<strong>HCH</strong>-1405 ED <strong>Department</strong> Decentralized Laboratory Testing Worksheet Apr-05 Lab Medicine<br />
<strong>HCH</strong>-2023 ED Psychological High Risk Assessment (ED)<br />
<strong>HCH</strong>-647 Educational Needs Flowsheet Nov.-1990 Jul-92 NICU/NBN<br />
<strong>HCH</strong>-1194 Elective Bowel Resection Care Path - Post Op Day 1 May-98 Jan.-01<br />
<strong>HCH</strong>-1195 Elective Bowel Resection Care Path - Post Op Day 2 May-98 Jan.-01<br />
<strong>HCH</strong>-1196 Elective Bowel Resection Care Path - Post Op Day 3 May-98 Jan.-01<br />
<strong>HCH</strong>-1197 Elective Bowel Resection Care Path - Post Op Day 4 May-98 Jan.-01<br />
<strong>HCH</strong>-1198 Elective Bowel Resection Care Path - Post Op Day 5 May-98 Jan.-01<br />
<strong>HCH</strong>-1199 Elective Bowel Resection Care Path - Post Op Day 6 May-98 Jan.-01<br />
<strong>HCH</strong>-1193 Elective Bowel Resection Care Path - Post Op Orders<br />
<strong>HCH</strong>-1192 Elective Bowel Resection Care Path - Pre Op Orders<br />
<strong>HCH</strong>-2190 Electroconvulsive Therapy (ECT) Consent Form - Acute Phase Oct. -09 J. Lounsbury<br />
<strong>HCH</strong>-2189 Electroconvulsive Therapy (ECT) Consent Form Continuation Maintenance Treatment Oct.-09 J. Lounsbury<br />
<strong>HCH</strong>-1821 Electroconvulsive Therapy (ECT) Discharge Instructions Oct-06 Jun-10 Psychiatry<br />
<strong>HCH</strong>-2267 Electroconvulsive Therapy (ECT) History Aug-10 Ivonne Hamm<br />
<strong>HCH</strong>-1822 Electroconvulsive Therapy (ECT) Nursing Recovery Phase Oct-06 Oct-10 K. Susco<br />
<strong>HCH</strong>-1820 Electroconvulsive Therapy (ECT) Treatment Record Dec.-06 Oct-10 Psychiatry<br />
<strong>HCH</strong>-2364 Electrodessication <strong>and</strong> Curettage (ED & C) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2321 Electrolyte Replacement Order Set Oct-11 J. Riemer<br />
<strong>HCH</strong>-1442 Electrophysiology Lab Orders Sept.-05 Mar-06 Electrophysiology<br />
<strong>HCH</strong>-1444 Electrophysiology Lab Post Device Implantation Orders Sept.-05 Mar-06 K. Coyne<br />
<strong>HCH</strong>-1443 Electrophysiology Lab Post EPS Ablation Orders Sept.-05 Mar-06 K. Coyne<br />
<strong>HCH</strong>-2118 Electrophysiology Lab Post Procedure PACU Ordes (EP Lab) K. Coyne<br />
<strong>HCH</strong>-1830 Electrophysiology Lab Tilt Table Worksheet (EP Lab) K. Coyne<br />
<strong>HCH</strong>-2187 Electrophysiology Pre-Printed Orders (EP Lab) Oct-09 K. Coyne<br />
<strong>HCH</strong>-2058 Emergency Information Disclosure Form (HIM)<br />
<strong>HCH</strong>-1958 Employee Health Toxcup Drug Screen Result Worksheet (Occ Med/Emp Health)<br />
<strong>HCH</strong>-1558 Employee Questionnaire Nuclear Magnetic Fields Screening OCC Med Dec-06 S. Barnosky- Occ Med<br />
<strong>HCH</strong>-2365 Enbrel (Etanercept) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2292 Encounter Note Oncology Feb-11 Jessie Riemer<br />
<strong>HCH</strong>-1628 ENT Patient Encounter (UMG) Jan-07 May-12 E.Wagner<br />
<strong>HCH</strong>-2158 Epidural Infusion Orders for Labor <strong>and</strong> Delivery Jul-09 Aug-10 C. Schramm<br />
<strong>HCH</strong>-866 Epidural Spinal Narcotics Orders Feb.-94 Feb.-06 Anesthesiology<br />
<strong>HCH</strong>-885 Epidural/Spinal PCA Narcotic Flowsheet Jun-94 Jan.-10 Nursing<br />
<strong>HCH</strong>-1917 Epworth Sleepiness Scale (Sleep Disorders Center)<br />
<strong>HCH</strong>-2251 Erythrocytapheresis Order May-10 Jan-12 M. Arsenault<br />
<strong>HCH</strong>-2231 Erythropoietin (EPO) Order Sheet Feb.-10 M. Arsenault<br />
<strong>HCH</strong>-1483 Evaluation OT Total Hip Arthoroplasty Jun-09 Jul-09 B.Boucher-Rehab<br />
<strong>HCH</strong>-2366 Excision Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1334 NO LONGER A CHART FORM Extended Stress Oximetry Test DEACTIVATED 10/2011<br />
8/3/2012 - 9:53 AM 9/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1272 Extended Type <strong>and</strong> Screen (Blood Bank Information Form) Feb.-99 Jan.-08<br />
<strong>HCH</strong>-2030 Extramural Autopsy Consent Form (JDH)<br />
<strong>HCH</strong>-2318 Face to Face Encounter Form Oct-11 Cathy Cruz<br />
<strong>HCH</strong>-2052 Fall Risk Flowsheet (UMG <strong>and</strong> JDH)<br />
<strong>HCH</strong>-1985 Fall Risk Flowsheet <strong>and</strong> Fall Prevention Treatment Plan<br />
<strong>HCH</strong>-2337 Fall Prevention Screening <strong>and</strong> Guideline Dec-11 J. Riemer<br />
<strong>HCH</strong>-2151 Falls Prevention Teaching Sheet<br />
<strong>HCH</strong>-2224 Falls Skin Neurological Assessment Feb.-10 Jan-11 Sue Goodrich<br />
<strong>HCH</strong>-1062 Family Education <strong>of</strong> the Hospitalized Infant Sept.-97 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-2020 Family History/Pedigree (UMG)<br />
<strong>HCH</strong>-2010 Farmington Surgery Center Anesthesiology Orders: Adult Perianesthesia Care (FSC) Jan-08 Jul-12 Carol Schramm<br />
<strong>HCH</strong>-1569 Fetal Ultrasound Growth Assessment Dec-06 Nancy Maxwell/OB GYN<br />
<strong>HCH</strong>-1135 Fever Neutropenia Teaching Nov.-97 Sept.-00<br />
<strong>HCH</strong>-1384 Fiberoptic Endoscopic Evaluation <strong>of</strong> Swallow (FEES) (Rehab) Apr-08 00-00 Rehab Services<br />
<strong>HCH</strong>-2367 Fluconazole Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2368 Fluorouracil (Carac, Efudex, Fluoroplex) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1432 Follow Up Patient Questionnaire Osteoporosis Center (UMG) 00-2005 Jun-09 Osteoporosis Clinic<br />
<strong>HCH</strong>-1833 Follow-Up Encounter Form Infectious Disease<br />
<strong>HCH</strong>-1599 Foot <strong>and</strong> Ankle New Patient Questionnaire (UMG) Apr-07 Oct-08 K.Clarke -Orthopaedics<br />
<strong>HCH</strong>-2081 Footmaxx Orthotics Authorization (UMG - Podiatry)<br />
<strong>HCH</strong>-1372 Four Hour Hold NSTevaluation Dec.-03 Oct-11 Gwyn Muscillo<br />
<strong>HCH</strong>-627 Frequent Vital Signs Flowsheet May-92 Oct.-08 NICU/NBN<br />
<strong>HCH</strong>-1900 Functional Capacity Evaluation (FCE) Modified Blankenship Protocol (Occ Med)<br />
<strong>HCH</strong>-1918 Functional Outcomes <strong>of</strong> Sleep Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-1436 Gastroenterology Follow Up Patient Visit Form Mar-06 Oct-06 Ute Schroeder-GI<br />
<strong>HCH</strong>-1435 Gastroenterology New Patient Visit Form Mar-06 Ute Schroeder-GI<br />
<strong>HCH</strong>-2271 Gastroenterology Plan <strong>of</strong> Care Sep-10 Jan-11 Ute Schroeder-GI<br />
<strong>HCH</strong>-1064 NO LONGER A CHART FORM Gastroesophageal Reflux DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1090 Gastrostomy Tube Button Sept.-97 Mar-08<br />
<strong>HCH</strong>-1289 General DC Instructions Ambulatory Patient Info Jul-99 Oct.-08<br />
<strong>HCH</strong>-1289G General Discharge Instructions Ambulatory GI Endoscopy Mar-01 May-06<br />
<strong>HCH</strong>-1289R General Discharge Instructions Ambulatory Imaging Patient Info Jul-99 Oct.-00<br />
<strong>HCH</strong>-2181 General Discharge Instructions Ambulatory Patient Info. - Spanish Oct.-09<br />
<strong>HCH</strong>-1289S General Discharge Instructions Ambulatory Post-Sedation May-06<br />
<strong>HCH</strong>-1642 General/Vascular Surgery New Patient Questionnaire (UMG) Sep-04 Dec-06<br />
<strong>HCH</strong>-1136 Generic Patient Teaching Nov.-97 Sept.-00<br />
<strong>HCH</strong>-2222 Geriatric Depression Scale (Short Form Jan.-10 R. Viens<br />
<strong>HCH</strong>-2079 Geriatric Patient Intake Flowsheet (UMG - Geriatrics)<br />
<strong>HCH</strong>-588 GeroPsych/Med/Surg/Onc Nursing Flowsheet Jan-91 Oct-11 Jessie Riemer<br />
<strong>HCH</strong>-1362 NO LONGER A CHART FORM Getting Ready for Baby's Discharge A worksheet for Parents DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1421 GI Endo Nursing Assessment Oct-05 Perioperative Nursing<br />
<strong>HCH</strong>-1284 GI Endoscopy Pre-printed Orders for Perioperative Nursing Care Jan.-99 Nov.-09<br />
<strong>HCH</strong>-2254 Goals Questionnaire May-10 Sigita Banevicius<br />
<strong>HCH</strong>-2369 Grise<strong>of</strong>ulvin Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2165 Group Activity Notes (Psychiatry) Aug-09 Jun-10 Grace Kutz<br />
<strong>HCH</strong>-2351 Group Progress Note Apr-12 Judith Lounsbury<br />
<strong>HCH</strong>-1368 GYN/ONC Encounter Note - Established Visit NO LONGER A CHART FORM Sept.-03 Dec.-06<br />
<strong>HCH</strong>-1367 GYN/ONC Encounter Note - New Patient / Established Patient / Consultation Sept.-03 Apr-12 Jessie Riemer<br />
<strong>HCH</strong>-1687 GYN/ONCOLOGY Treatment History<br />
8/3/2012 - 9:53 AM 10/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1862 Hamilton Depression Scale (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-1505 H<strong>and</strong> Database Sep-06 Barbara Boucher/Rehab<br />
<strong>HCH</strong>-1516 H<strong>and</strong> Evaluation - Rehab Sep-06<br />
<strong>HCH</strong>-2273 H<strong>and</strong> Patient Follow-up Questionnaire Oct-10 Kelly Clarke<br />
<strong>HCH</strong>-2295 H<strong>and</strong> Therapy Referral (Ortho) Feb-11 Mar-11 Kelly Clarke<br />
<strong>HCH</strong>-1503 H<strong>and</strong> Therapy Splint Evaluation Replaced by <strong>HCH</strong>-2310 Aug-06 B. Boucher/Rehab<br />
<strong>HCH</strong>-2274 Head <strong>and</strong> Neck Chemotherapy/Radiation Symptom Flow Sheet Oct-10 Jessie Riemer<br />
<strong>HCH</strong>-2082 Health Assessment Questionnaire Disability Form (UMG)<br />
<strong>HCH</strong>-1538 Health History Questionnaire UMG Nov-06 M. Hein- UMG<br />
<strong>HCH</strong>-2325 Hearing Aid Introduction Oct-11 Elissa Wagner/Donna G<strong>and</strong>za<br />
<strong>HCH</strong>-2076 Hearing H<strong>and</strong>icap Inventory for Adults Screening Version (UMG)<br />
<strong>HCH</strong>-2394 Heart Failure Education Consult Form Jul-12 J. Ryan/Linda Manzelli<br />
<strong>HCH</strong>-1455 NO LONGER A CHART FORM Heated Humidified Nasal Cannula Flowsheet DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1302 Helicobacter Pylori Tissue Assay Oct.-99 Mar-06 Gastroenterology<br />
<strong>HCH</strong>-1939 Heme/Onc Treatment Orders (Cancer Center)<br />
<strong>HCH</strong>-1692 Hematology Oncology Inpatient Note Nov-06 Dec.-09 Donna Pryor<br />
<strong>HCH</strong>-900 Hemodialysis Orders Jun-06 Jun-10<br />
<strong>HCH</strong>-1660 Hepatitis B Consent Tuberculosis Screening (Employee Health/OCC Med) Jul-07 Aug-07 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1130 Hickman Catheter Nov.-97 Sept.-00<br />
<strong>HCH</strong>-813 NO LONGER A CHART FORM High Frequency Oscillatory Ventilation Flow Sheet DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1346 High Risk Assessment (Dept <strong>of</strong> Psychiatry) Dec-01 Mar-06<br />
<strong>HCH</strong>-1415 HIP EVALUATION Oct-05 Rehab<br />
<strong>HCH</strong>-1255 Patient & Family Teaching Record - Hip Fracture Feb.-99 Dec.-00<br />
<strong>HCH</strong>-1257 Hip Fracture Care Path Feb.-99<br />
<strong>HCH</strong>-2012 History <strong>and</strong> Physical Encounter (Neurosurg Comprehensive Spine Center UMG)<br />
<strong>HCH</strong>-2236 History <strong>and</strong> Physical Examination Admission Note Mar-10 May-10 Steve Angus, MD<br />
<strong>HCH</strong>-1523 History <strong>and</strong> Physical Exam UMG Oct-06 UMG-M. Hein<br />
<strong>HCH</strong>-1740 History <strong>and</strong> Physical Examination <strong>and</strong> Immunication Employee Health<br />
<strong>HCH</strong>-606 HIV Consent Form Jan-90 Aug.-06<br />
<strong>HCH</strong>-2370 Humira (Adalimumab) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-566 ICU Flow Sheet Mar-88 Nov-11 K. Coyne - ICU<br />
<strong>HCH</strong>-1067 NO LONGER A CHART FORM IleostomyColostomy DEACTIVATED 10/2011<br />
<strong>HCH</strong>-2260 Image Storage Notification Jun-10 Linda Clark<br />
<strong>HCH</strong>-926 Imaging <strong>and</strong> Interventional Nursing Record Sept.-94 Jun-07 Radiology<br />
<strong>HCH</strong>-1745 Imiglucerase Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2371 Imiquimod (Aldara, Zyclara) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2173 Immediate Post-Op C-Section <strong>and</strong> Vaginal Delivery Orders Sep-09 Feb-12 SueEllen Goodrich<br />
<strong>HCH</strong>-1544 Immunization Documentatin Screening Form UMG OCC MED Emp Hlth Nov-06 Feb-11 Janet Pinto<br />
<strong>HCH</strong>-1837 Immunization Record (Dept <strong>of</strong> Infectious Disease/Travel Medicine<br />
<strong>HCH</strong>-1831 Implanted Cardioverter Defibrillator (ICD) Care <strong>and</strong> Patient Discharge Instructions<br />
<strong>HCH</strong>-2372 Imuran (Azathioprine) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2328 Infant Safety <strong>and</strong> Fall Prevention Contract Nov-11 Feb-12 SueEllen Goodrich<br />
<strong>HCH</strong>-2329 Infant Safety <strong>and</strong> Fall Risk Identification Assessment Nov-11 May-12 SueEllen Goodrich<br />
<strong>HCH</strong>-1959 Infertility Encounter Note (Urology)<br />
<strong>HCH</strong>-1468 Infertility Summary Jun-06 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-2038 Infliximab (Remicade) After-Care Patient Instructions (Rheum Infusion)<br />
<strong>HCH</strong>-1897 Infliximab (Remicade) After-Care Patient Instructions (UMG)<br />
<strong>HCH</strong>-2048 Infliximab (Remicade) Infusion Record (Rheum Infusion)<br />
8/3/2012 - 9:53 AM 11/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1894 Infliximab (Remicade) Infusion Treatment Record (Dermatology)<br />
<strong>HCH</strong>-1898 Infliximab (Remicade) Pre-Infusion Patient Assessment Checklist (Derm)<br />
<strong>HCH</strong>-1752 Infliximab (Remicade) Pre-Printed Order Set Nov-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-1161 Influenza Group Immunization Consent Form Feb.-98 Sept.-09<br />
<strong>HCH</strong>-2180 Influenza Group Immunization Consent Form (H1N1) Oct.-09 N. Dupont<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2335 Informed Consent 308-NM Ultraviolet B (UVB) Laser Phototherapy Dec-11<br />
Sonnenberg<br />
<strong>HCH</strong>-2004 Informed Consent - Allergy Testing <strong>and</strong> Treatment (UMG Otolaryngology)<br />
<strong>HCH</strong>-2063 Informed Consent - Ambulatory Services/Procedures<br />
<strong>HCH</strong>-2182 Informed Consent & Authorization for Admin. Of Anesthesia Services - Spanish Oct.-09<br />
<strong>HCH</strong>-1984 Informed Consent - Biopsy (JDH Derm) Dec-07 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1982 Informed Consent - Botox Injection for Spasodic Dysphonia (UMG ENT)<br />
<strong>HCH</strong>-1983 Informed Consent - Botox Injection for Torticollis (UMG ENT)<br />
<strong>HCH</strong>-2084 Informed Consent - Bronchoscopy<br />
<strong>HCH</strong>-2085 Informed Consent - Contrast Echocardiography - Calhoun Cardiology Center<br />
<strong>HCH</strong>-1979 Informed Consent - Electrodesiccation <strong>and</strong> Curettage (UMG Derm)<br />
<strong>HCH</strong>-2132 Informed Consent - Lumbar Puncture<br />
<strong>HCH</strong>-2002 Informed Consent - MOHS Micrographic Surgery (JDH Derm) Jan-08 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1981 Informed Consent - pH Probe Placement (UMG ENT)<br />
<strong>HCH</strong>-1980 Informed Consent - Pillar Palatal Implant (UMG ENT)<br />
<strong>HCH</strong>-1999 Informed Consent - Radiesse Dermal Filler (Derm)<br />
<strong>HCH</strong>-2001 Informed Consent - Restylane Dermal Filler (UMG Derm)<br />
<strong>HCH</strong>-2003 Informed Consent - Scissor Excision (JDH Derm) Jan-08 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-2028 Informed Consent - V beam Treatment (Derm)<br />
<strong>HCH</strong>-2078 Informed Consent <strong>and</strong> Authorization for Administration <strong>of</strong> Anesthesia Services Sep-08 Apr-12 Carol Schramm<br />
<strong>HCH</strong>-1995 Informed Consent Asthma Exercise Challenge Test (Pulm Function Lab)<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2341 Informed Consent: C<strong>and</strong>ida Dec-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1993 Informed Consent Cardiopulmonary Exercise Test (Pulm Function Lab)<br />
<strong>HCH</strong>-1677 Informed Consent Dobutamine Stress Echo Testing<br />
<strong>HCH</strong>-1799 Informed Consent Exercise StresS Echo Testing Mar-07<br />
<strong>HCH</strong>-1801 Informed Consent Exercise Stress Test (Cardiology Center)<br />
<strong>HCH</strong>-2031 Informed Consent for Infliximab (Remicade) Infusion Therapy (Rheum Infusion)<br />
<strong>HCH</strong>-1808 Informed Consent for Laser In-Situ Keratomileusis (Lasik) (UMG)<br />
<strong>HCH</strong>-2226 Informed Consent for Psoralen Ultra Uva (Puva) Phototherapy Jan.-10 Nov-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-2051 Informed Consent for Reclast (Zoledronic Acid) Infusion<br />
<strong>HCH</strong>-1925 Informed Consent for Total Body Skin Imaging (Derm)<br />
<strong>HCH</strong>-2089 Informed Consent for Transesophageal Echocardiogram (TEE)<br />
<strong>HCH</strong>-2227 Informed Consent for Ultraviolet B (UVB) Narrow B<strong>and</strong> Light Phototherapy Jan.-10 Nov-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1495 Informed Consent for Vaccination (Immunization) UMG Aug-06 Ute Schroeder-GI<br />
<strong>HCH</strong>-2066 Informed Consent for Zometa Infusion (UMG Rheumatology)<br />
<strong>HCH</strong>-1976 Informed Consent Infliximab (Remicade) Infusion Therapy (Derm)<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2340 Informed Consent: Injection <strong>of</strong> Triamcinolone Acetonide Dec-11<br />
Sonnenberg<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2342 Informed Consent: Laser Dec-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1994 Informed Consent Methacholine Challenge Test (Pulm Function Lab)<br />
<strong>HCH</strong>-2029 Informed Consent Micro-Dermabrasion (Derm)<br />
<strong>HCH</strong>-1798 Informed Consent Nuclear Exercise Stress Test Mar-07<br />
8/3/2012 - 9:53 AM 12/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1735 Informed Consent Pharmacological Nuclear Stress Test Nov-06 Dec-11 Jayne Schumacher<br />
<strong>HCH</strong>-1926 Informed consent Photorefractive Keratectomy (PRK Ophthalmology)<br />
<strong>HCH</strong>-1312 Informed Consent VBAC Jan.-00 Jul-06 OB/Gyn<br />
<strong>HCH</strong>-2346 Infusion Reaction Order Set Feb-12 Jun-12 Jessie Riemer<br />
<strong>HCH</strong>-514 Infusion record Nov-91 May-07<br />
<strong>HCH</strong>-1962 Initial Screening Form (Psych)<br />
<strong>HCH</strong>-2153 Initial Suicide Risk Screening (Psych)<br />
<strong>HCH</strong>-1809 Injection Administration Flow Sheet (UMG)<br />
<strong>HCH</strong>-1282 Inpatient Database (Nursing) Feb.-99 Jul-08<br />
<strong>HCH</strong>-1482 Inpatient OT Eval Jun-09 Jul-09 B. Boucher-Rehab<br />
<strong>HCH</strong>-2057 Inpatient Physical Therapy Evaluation<br />
<strong>HCH</strong>-1944 Inpatient Pre-ECT Treatment Checklist (Psych)<br />
<strong>HCH</strong>-1093 Inpatient Pre-Operative Checklist Aug-98 Mar-11 Carol Schramm<br />
<strong>HCH</strong>-2229 Inpatient Pre <strong>and</strong> Post-ECT Orders Feb.-10 J. Lounsbury<br />
<strong>HCH</strong>-2022 Inpatient Psychiatric Admission Checklist (Inpt Psych) Nursing/Psych<br />
<strong>HCH</strong>-2080 Inpatient Transfer H<strong>and</strong> Off Communication Form (ISBAR) Oct-08 Aug-11 Am<strong>and</strong>a Darcey<br />
<strong>HCH</strong>-2112 Inpatient Transfer H<strong>and</strong> Off Communication Form (ISBAR) Labor/Delivery/OB 00-05 Apr-10 Sue Goodrich<br />
<strong>HCH</strong>-2108 Inpatient Transfer H<strong>and</strong>-Off Communication Form (ISBAR) Psychiatry<br />
<strong>HCH</strong>-1686 Instrumental ADL Scale (UMG) Geriatrics<br />
<strong>HCH</strong>-2338 Insulin Infusion - Adult ICU Dec-11 Julie Ann Laflamme<br />
<strong>HCH</strong>-2161 Insulin Infusion - Conventional Glycemic Control: Medical Surgical Patients Dec.-09<br />
<strong>HCH</strong>-2160 Insulin Infusion - Tight Glycemic Control: Cardiothoracic Patients<br />
Insulin/Blood Glucose Flow Sheet (UMG)<br />
Dec.-09<br />
<strong>HCH</strong>-1619<br />
Apr-06 Jan-07 C.Mensing-Diabetes Education<br />
<strong>HCH</strong>-598 Intake <strong>and</strong> Output Record (JDH) Jul-03 Jul-03<br />
<strong>HCH</strong>-906 Intake Output Record (Inpatient Psychiatry) May-94 Apr-07 Nursing/Psych.<br />
<strong>HCH</strong>-1908 Intake Questionnaire (Rehab/Sports Med) Sep-07 Apr-10 B. Boucher<br />
<strong>HCH</strong>-1899 Intense Pulse Light Flowsheet (Derm) 00-2005 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1960 Intense Pulse Light Laser Test Sites (Derm)<br />
<strong>HCH</strong>-1784 Intense Pulse Light Skin Typing Questionnaire (JDH Derm) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-2313 Interdisciplinary Admission/Discharge History & Physical Record - Well Newborns Aug-11 Oct-11 Elaine Gerry<br />
<strong>HCH</strong>-852 Interdisciplinary Database/Initial Evaluation (Psychiatry Inpatient) Dec.-90 Oct.-09 Nursing Psych.<br />
<strong>HCH</strong>-1308 Interdisciplinary Integrated Summary (Psych) Nov.-99 Feb.-08 Psychiatry<br />
<strong>HCH</strong>-1904 International Consultation on Incontinence Questionnaire (Urology)<br />
<strong>HCH</strong>-1875 International Normalized Ratio (INR) Worksheet (Electrophysiology)<br />
<strong>HCH</strong>-2024 Interpreter Services Encounter<br />
<strong>HCH</strong>-1874 Interpreter Services Waiver Jun-07 Apr-10<br />
<strong>HCH</strong>-2075 Interpreter Services Waiver (Spanish) DEACTIVATED 2/17/2011 M<strong>and</strong>y Reynolds<br />
<strong>HCH</strong>-2184 Interventional Cardiology Nursing Assessment & Teaching Record Oct.-09 Jun-11 Cathy Ingriselli<br />
<strong>HCH</strong>-2216 Interventional Cardiology Post Procedure Flowsheet Dec.-09 K.Coyne<br />
<strong>HCH</strong>-2162 Interventional Cardiology Pre Printed Orders Jul-09 Apr-12 K. Coyne<br />
<strong>HCH</strong>-2215 Interventional Radiology Discharge Instructions Dec.-09 M. Bellantuono<br />
<strong>HCH</strong>-1892 Interventional Radiology Nursing Assessment <strong>and</strong> Teaching Record Jul-07 Oct.-2009 C. Schramm- Nursing<br />
<strong>HCH</strong>-1358 Interventional Radiology Pre-printed Orders Oct.-01 Jan-12 Carolyn Brackett/Radiology<br />
<strong>HCH</strong>-2121 Interventional Radiology Procedure Documentation Mar-09 Mar-10 M. Bellantuono<br />
<strong>HCH</strong>-1427 Interventional Radiology-special procedures req - Order from warehouse (Moore) Dec-05 Sep-07 MOORE FORM<br />
<strong>HCH</strong>-1454 Intra Aortic Balloon Pump Flowsheet May-06 ICU<br />
<strong>HCH</strong>-1526 Intradermal Titration Sheet Set #1 (Otolaryngology) May-07 E. Wagner<br />
8/3/2012 - 9:53 AM 13/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1527 Intradermal Titration Sheet Set #2 (Otolaryngology) May-07 E. Wagner<br />
<strong>HCH</strong>-1834 Intradermal Titration Sheet Set #3 (Otolaryngology)<br />
<strong>HCH</strong>-2373 Intralesional Immunotherapy - C<strong>and</strong>ida Albicans Antigen Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2374 Intralesional Steroid Injection Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1963 Intrauterine Device Questionnaire (UMG OB/GYN)<br />
<strong>HCH</strong>-2280 Intravenous Heparin Nomogram - Acute Ischemic Stroke Nov-10 Jan-11 Jessie Riemer<br />
<strong>HCH</strong>-2293 Intravenous Heparin Nomogram - Disseminated Intravascular Coagulation Feb-11 Tom Pizz<strong>of</strong>errato<br />
<strong>HCH</strong>-2282 Intravenous High Intensity Heparin Nomogram - Venous Thrombosis (DVT/PE) Nov-10 May-12 Jessie Riemer<br />
<strong>HCH</strong>-1747 Intravenous Immune Globulin Pre-Printed Order Set Dec-06 Oct-11 Jessie Riemer<br />
<strong>HCH</strong>-2281 Intravenous Low Intensity Heparin Nomogram Cardio Vasc Interven Proc & Ischemic Stroke Nov-10 Jul-11 Tom Pizz<strong>of</strong>errato/J. Riemer<br />
<strong>HCH</strong>-1006 Involuntary Commitment Proc Current Med <strong>List</strong>ing <strong>and</strong> Side Effects Mar-96 Apr-06<br />
<strong>HCH</strong>-1755 Iron Sucrose Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2375 Itraconazole (Sporanox) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1950 Joint <strong>and</strong> Extremity Questionnaire (Diagnostic Imaging) Oct-07 Aug-10<br />
<strong>HCH</strong>-2376 Ketoconazole Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1416 KNEE EVALUATION Oct-05 Rehab<br />
<strong>HCH</strong>-1556 Lab Result Letter - OCC Med Employee Health Dec-06 Jan-12 S.Barnosky - Occ Med (J. Pinto)<br />
<strong>HCH</strong>-2213 Labor <strong>and</strong> Delivery Flowsheet Dec.-09 Jul-10 Toni Leers<br />
<strong>HCH</strong>-1004 Labor <strong>and</strong> Delivery Summary Sheet Mar-96 Apr-06<br />
<strong>HCH</strong>-2397 Laboratory Medicine Requisition Jul-12 Anuja Durman<br />
<strong>HCH</strong>-1583 Laboratory Request Form for Molecular Study-Human Genetics Laboratories Jul-05 Dec-06 Lisa Ramsdell/UMG Genetics<br />
<strong>HCH</strong>-1584 Laboratory Request Form for Oncology Study-Human Genetics Laboratories Aug-05 Dec-06 Lisa Ramsdell/UMG Genetics<br />
<strong>HCH</strong>-1141 Laparotomy Care <strong>of</strong> the Patient Admitted to OBGYN (Patient & Family Teaching) Nov.-97 Sept.-00<br />
<strong>HCH</strong>-1540 Laryngeal Function Study UMG Nov-06 Elissa Wagner<br />
<strong>HCH</strong>-1566 Laser Eye Examination OCC Med Employee Health Nov-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-2264 Laser Photocoagulation for Retinopathy <strong>of</strong> Prematurity- St<strong>and</strong>ard Order Sheet Aug-10 Therese Donovan<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2332 Laser Phototherapy Patient Instructions Nov-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1901 Laser Vision Correction Bilateral Consent (Ophthalmology)<br />
<strong>HCH</strong>-1903 Laser Vision Questionnaire (Ophthalmology)<br />
<strong>HCH</strong>-1565 Latex Allergy Screening Questionnaire OCC Med Nov-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1776 Letter - Labs Needed for Clearance (UMG OCC MED/Emp Health) Jan-07 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-2377 Levaquin (Lev<strong>of</strong>loxacin) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2154 Licensed Practitioner Communication Record (Psych)<br />
<strong>HCH</strong>-1417 LUMBAR EVALUATION Oct-05 Rehab<br />
<strong>HCH</strong>-1953 Lumbar Spine Questionnaire (Diagnostic Imaging) Oct-07 Aug-10 Radiology<br />
<strong>HCH</strong>-1287 Lyme Disease Vaccine-Immunization Consent Form Jun-99 Feb.-06<br />
<strong>HCH</strong>-1948 Magnetic Resonance Imaging Checklist-Inpatient Oct.-07 Dec.-09<br />
<strong>HCH</strong>-2207 Magnetic Resonance Imaging Checklist-Outpatient Dec.-09 Radiology<br />
<strong>HCH</strong>-1658 M<strong>and</strong>atory Annual Certification Enrollment (Employee Health)<br />
<strong>HCH</strong>-1250 Patient <strong>and</strong> Family Teaching Record -Mastectomy/Lumpectomy Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1420 <strong>Master</strong> Nutrition Assessment Form Nov-05 Food & Nutrition<br />
<strong>HCH</strong>-1824 NO LONGER A CHART FORM <strong>Master</strong> Psychiatric Nursing Treatment Plan (Psych 1) DEACTIVATED 9/09<br />
<strong>HCH</strong>-1825 <strong>Master</strong> Psychiatric Nursing Treatment Plan (Psych 3)<br />
<strong>HCH</strong>-1582 Maternal Serum Screen for Birth Defects Jan-03 Dec-06 Lisa Ramsdell/UMG Genetiics<br />
<strong>HCH</strong>-2203 Mechanical Ventilation Flowsheet B Nov.-09 J. Schoenewolff<br />
<strong>HCH</strong>-2178 Med 4/ Med Stepdown Nursing Flow Sheet Jan-91 Oct-11 Jessie Riemer<br />
<strong>HCH</strong>-1252 Patient & Family Teaching Record - Medical Admission General Teaching Oct.-98 Dec-00<br />
8/3/2012 - 9:53 AM 14/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1759 Medical Clearance for Hearing Aid C<strong>and</strong>idacy<br />
<strong>HCH</strong>-629 Medical Oncology for Chemotherapy Discharge Summary Apr-92 Sept.-06 Medical/Oncology<br />
<strong>HCH</strong>-1786 Medical Photography Consent (Dermatology) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-551A Medical Record Request for Information for Treatment Purposes Only Aug-92 Apr-03 Medical Records-E.Albini<br />
<strong>HCH</strong>-127 Medical Surgical Procedure Consent<br />
<strong>HCH</strong>-1644 Medical Toxicology New Patient Questionnaire (UMG) Dec-06<br />
<strong>HCH</strong>-1065 Medication Administration at Home Sept.-97 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-1479 Medication Administration Flow Sheet (UMG) Jul-06 Mar-07 Linda Clark UMG Clinical<br />
<strong>HCH</strong>-307 Medication Administration Record (MAR) - Order from warehouse (Moore)<br />
<strong>HCH</strong>-2147 Medication Directions, Diagnostic Tests & One Time Medication Administration Orders (PHP)<br />
<strong>HCH</strong>-1447 Medication Reconciliation Form May-06 00-00 UMG<br />
<strong>HCH</strong>-1494 Medication Record - UMG Jun-00 Apr-07 M. Hein-UMG<br />
<strong>HCH</strong>-1112 Medication Refill Recording Form Oct.-97 Apr-06<br />
<strong>HCH</strong>-1131 Medication Teaching Nov.-97 Sept.-00<br />
<strong>HCH</strong>-1440 Medication Use Agreement Nov-04 Mar-06 UMG<br />
<strong>HCH</strong>-2163 Mental Health Bill <strong>of</strong> Rights<br />
<strong>HCH</strong>-1456 Metered Dose Inhalers Clinical Assessment Evaluation Form May-06 Respiratory Therapy<br />
<strong>HCH</strong>-2378 Methotrexate Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1936 Methotrexate Flow Sheet (Derm) Oct-07 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1780 Methotrexate Release Form (JDH Dermatology) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-1449 MFICU 4 Hour Hold Apr-06 Jun-09<br />
<strong>HCH</strong>-759 MFICU OBGYN Database Dec.-90 Nov.-99 Nursing<br />
<strong>HCH</strong>-1934 Microdermabrasion Procedure Note (Derm)<br />
<strong>HCH</strong>-2379 Minocycline Jul-12 Jane Grant-Kels<br />
L.Clark- UMG Clinical<br />
<strong>HCH</strong>-1489 Missed Appointment Letter UMG Jan-02 Aug-06 Informatics<br />
<strong>HCH</strong>-1757 Missed Appointment Letter UMG - Pedi Opthalmology<br />
<strong>HCH</strong>-2109 Missing Encounter Reconstruction Notification (FOR HIM USE ONLY)<br />
<strong>HCH</strong>-893 Modified Barium Swallow Evaluation Jul-94 Apr-08<br />
<strong>HCH</strong>-1383 Modified Barium Swallow Evaluation (Rehab) Apr-08 00-00 Rehab Services<br />
<strong>HCH</strong>-1734 MOHS Dermatology Plan <strong>of</strong> Care<br />
<strong>HCH</strong>-1612 MOHS Operative Note Nov-06 Cathy Sonnenberg<br />
<strong>HCH</strong>-1919 Morning Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-1948 MRI Checklist-Inpatient Oct-07 Oct-11 Radiology<br />
<strong>HCH</strong>-2207 MRI Checklist-Outpatient Oct-07 Apr-12 Radiology / Carolyn Brackett<br />
<strong>HCH</strong>-611 MRI Consultation Request - Order from warehouse (Moore) Dec.-05 Nov-11<br />
<strong>HCH</strong>-544 MRI Patient History Safety Screening<br />
<strong>HCH</strong>-1300 Multidisciplinary Database PHP Dec.-90 Jan.-02 Psych J. Lounsbury<br />
<strong>HCH</strong>-1413 Multidisciplinary Heart Failure Prevention Education Sep-05 Oct-11 Linda Mickelson<br />
<strong>HCH</strong>-1823 Multidisciplinary Initial Treatment Plan (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-2170 Multidisciplinary Treatment Plan - Adult Inpatient (Psychiatry) Sept.-09 Nov.-09 Psych.- J.Lounsbury<br />
<strong>HCH</strong>-2200 Multidisciplinary Treatment Plan - Adult Inpatient - Update Nov.-09 Psych.- J.Lounsbury<br />
<strong>HCH</strong>-1856 NO LONGER A CHART FORM Multidisciplinary Treatment Plan Alcohol Detoxification Opiate Detoxification DEACTIVATED 9/09<br />
<strong>HCH</strong>-1850 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Altered Health DEACTIVATED 9/09<br />
<strong>HCH</strong>-1853 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Discharge Planning DEACTIVATED 9/09<br />
<strong>HCH</strong>-1855 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Impaired Cognitive Function DEACTIVATED 9/09<br />
<strong>HCH</strong>-1852 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Individual Coping Impaired DEACTIVATED 9/09<br />
8/3/2012 - 9:53 AM 15/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1854 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Mood Disorder DEACTIVATED 9/09<br />
<strong>HCH</strong>-1857 Multidisciplinary Treatment Plan - PHP/IOP Altered Health<br />
<strong>HCH</strong>-1858 Multidisciplinary Treatment Plan - PHP/IOP Discharge Planning<br />
<strong>HCH</strong>-1859 Multidisciplinary Treatment Plan - PHP/IOP Mood/Anxiety/Thought Disorder<br />
<strong>HCH</strong>-1860 Multidisciplinary Treatment Plan - PHP/IOP Substance Abuse/Dependence<br />
<strong>HCH</strong>-1965 Multidisciplinary Treatment Plan - Problem: Grave Disability (Psychiatry)<br />
<strong>HCH</strong>-1964 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Problem: Personality Disorder (Psychiatry) DEACTIVATED 9/09<br />
<strong>HCH</strong>-1966 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Problem: Risk <strong>of</strong> Violence (Psychiatry) DEACTIVATED 9/09<br />
<strong>HCH</strong>-1851 NO LONGER A CHART FORM Multidisciplinary Treatment Plan - Thought Process Altered DEACTIVATED 9/09<br />
<strong>HCH</strong>-1945 Multidisciplinary Treatment Plan (Psych)<br />
<strong>HCH</strong>-1123 NO LONGER A CHART FORM Multidisciplinary Treatment Plan Facesheet (Psych Inpt) DEACTIVATED 9/09<br />
<strong>HCH</strong>-1946 Multidisciplinary Treatment Plan Problem <strong>List</strong> (Psych)<br />
<strong>HCH</strong>-1978 Multiple Sleep Latency Test Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-1977 Multiple Sleep Latency Test Technologist Log (Sleep Disorders Center)<br />
S. Banevicius/Tina Champagne,<br />
<strong>HCH</strong>-2398 My Discharge Plan (Sensory Diet: Crisis Intervention Worksheet) Jul-12<br />
copyright owner<br />
<strong>HCH</strong>-1066 NO LONGER A CHART FORM Myelomeningocele DEACTIVATED 10/2011<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2345 Nail Surgery Wound Care Instructions Feb-12<br />
Sonnenberg<br />
<strong>HCH</strong>-1457 NO LONGER A CHART FORM Nasal Continuous Positave Airway Pressure Flowsheet DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1088 NO LONGER A CHART FORM Nasogastric (NG) Tube Feedings DEACTIVATED 10/2011<br />
<strong>HCH</strong>-2339 Natalizumab (Tysabri®) Pre-printed Order Set Dec-11 Jessie Riemer<br />
<strong>HCH</strong>-683 Neonatal Abstinence Scoring Record Aug.-92 Sep-11 NICU/NBN<br />
<strong>HCH</strong>-587 Neonatal Intensive Care Flowsheet (NICU) - Order from warehouse (Moore) Jul-91 Feb.-01 Nursing<br />
<strong>HCH</strong>-1818 NO LONGER A CHART FORM Neonatal Intensive Care Respiratory Flowsheet (NICU) DEACTIVATED 10/2011<br />
<strong>HCH</strong>-809 Neonatal Neurological Assessment/Seizure Assessment Flowsheet 00-05 Sep-11 Nursing<br />
<strong>HCH</strong>-1321 Neonatal Nutrition Note Dec.-00 Feb.-06 Food & Nutrition<br />
<strong>HCH</strong>-495 Neonatal Parenteral Nutrition Fluid Orders May-87 Feb-08 Neonatology<br />
<strong>HCH</strong>-2290 NO LONGER A CHART FORM Neonatal Point <strong>of</strong> Care Testing (POCT) Reference Ranges DEACTIVATED 10/2011<br />
<strong>HCH</strong>-2212 Neonatal Skin Condition Score Dec.-09 Sep-11 S.Zaffetti<br />
<strong>HCH</strong>-2380 Neoral (Cyclosporine) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-960 Neurological Evaluation (Rehab) Sept.-06 Rehab Services<br />
<strong>HCH</strong>-1217 Neurological History <strong>and</strong> Physical Encounter Form (UMG) Sept.-98<br />
<strong>HCH</strong>-1475 Neuromuscular Speech Pathology Assessment Jul-06<br />
<strong>HCH</strong>-1775 Neurosurgery Encounter Sheet (UMG) 00-01 Jan-07 Neurosurgery<br />
<strong>HCH</strong>-2127 Neurosurgery History <strong>and</strong> Physical (UMG)<br />
<strong>HCH</strong>-2126 Neurosurgery New Patient Questionnaire (UMG)<br />
<strong>HCH</strong>-2125 Neurosurgery Re-Evaluation (UMG)<br />
<strong>HCH</strong>-1768 New Patient Breast Questionnaire (Cancer Center) Jan-07 Neag Cancer Center<br />
<strong>HCH</strong>-2299 New Patient Dispensation Apr-11 Jul-12 Kelly Clarke<br />
<strong>HCH</strong>-1771 New Patient Questionnaire - Gastroenterology/Hepatology (UMG) Dec-06 Ute Schroeder<br />
<strong>HCH</strong>-1643 New Patient Questionnaire Plastic Surgery (UMG) Jan-03 Dec-06 C.Sonnenberg-Surgery<br />
<strong>HCH</strong>-2268 Newborn Admission Discharge Examination Replaced by <strong>HCH</strong>-2313 Aug-10 Elaine Gerry<br />
<strong>HCH</strong>-1414 Newborn Eye Exam Order Sheet Nov-05 NICU<br />
<strong>HCH</strong>-1496 Newborn Hearing Screening Program Aug-06 Apr-12 T. Donovan-NICU<br />
<strong>HCH</strong>-1428 NICU March <strong>of</strong> Dimes NICU Family Support Dec-05 Clinical Operations Admin<br />
<strong>HCH</strong>-808 NICU NBN Digitalization Orders Oct.-93 Mar-04 Pediatrics<br />
<strong>HCH</strong>-807 NICU NBN Digoxin Maintenance Orders Oct.-93 Pediatrics<br />
<strong>HCH</strong>-1804 NICU Transitional Clinic History (UMG Neonatology)<br />
8/3/2012 - 9:53 AM 16/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1791 NICU Transitional Clinic Patient Information Jan-07 N.Maxwell/OB-GYN<br />
<strong>HCH</strong>-1805 NICU Transitional Clinic Physical Exam (UMG/Neonatology)<br />
<strong>HCH</strong>-1885 NO LONGER A CHART FORM CAN/MHW Admission Checklst (Psychiatry)<br />
<strong>HCH</strong>-972 NO LONGER A CHART FORM PEC Admission Checklist (Psych Inpatient)<br />
<strong>HCH</strong>-2145 NO LONGER A CHART FORM Perioperative Transfer H<strong>and</strong>-Off (ISBAR)<br />
<strong>HCH</strong>-1348 NO LONGER A CHART FORM Staff Restraint Seclusion Debriefing Form<br />
<strong>HCH</strong>-1931 NO LONGER A CHART FORM Universal Protocol Procedural Checklist (NICU/Newborn Nursery)<br />
<strong>HCH</strong>-1373 Non-Invasive Cardiology Procedure Requisition Jan-04 Feb-12 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-1101 Non-Violent/Non-Sef Destructive Restraint Order Sheet Oct.-97 May-12 Am<strong>and</strong>a Darcey<br />
<strong>HCH</strong>-970 Notification <strong>of</strong> Internal Review Process for Adm <strong>of</strong> Medication w/o Consent Sept.-95 Aug-10 J. Lounsbury<br />
<strong>HCH</strong>-355A Nuclear Medicine Consultation Request (Radiology) - Order from warehouse (Moore) Feb.-07<br />
<strong>HCH</strong>-1319 Nursery Discharge Sheet Jun-00 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-2275 Nursing Assessment (A.A.C.U.) Oct-10 Mar-12 Jessie Riemer<br />
<strong>HCH</strong>-1046 Nursing Assessment (Cancer Center/Med Surg 5) Jun-97 Jan-12 Donna Pryor / Jessie Riemer<br />
<strong>HCH</strong>-1258 Nursing Database - Well Newborns Only Replaced by <strong>HCH</strong>-2313 Feb.-99 Mar-04<br />
<strong>HCH</strong>-890 Nursing Database Newborn Nursery Dec.-90 Sep-11<br />
<strong>HCH</strong>-1767 Nursing Flowsheet (Cancer Center/Med Surg 5) Jan-07 Sep-07 D. Pryor Neag Cancer Center<br />
<strong>HCH</strong>-869 Nursing Flowsheet (Oncology 6) Sept.-94 Oct.-07 Nursing<br />
<strong>HCH</strong>-1144 Nursing Nutrition Screening Form Nov.-97 Aug.-98<br />
<strong>HCH</strong>-1438 Nursing Patient Care Plan Mar-06 Nursing<br />
<strong>HCH</strong>-1870 Nursing Procedure Record (Electrophysiology Lab)<br />
<strong>HCH</strong>-2169 Nursing Progress Note Adult Inpatient (Psych) Sept.-09 Nov-10 Psych. J.Lounsbury<br />
<strong>HCH</strong>-951 Nutrition Discharge Summary Sept.-04 May-06<br />
<strong>HCH</strong>-1453 Nxstage Continual Renal Replacement Therapy Flowsheet May-06 ICU<br />
<strong>HCH</strong>-1625 OB/GYN Encouner (UMG OB/GYN) Apr-07 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-1570 OB/GYN New Patient Questionnaire (UMG) Dec-06 Nancy Maxwell/OB GYN<br />
<strong>HCH</strong>-1469 OB/GYN Pelvic Ultrasound Jun-06 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-2053 Observation Documentation Record Nursing (JDH)<br />
<strong>HCH</strong>-919 Observation Status (Message to Patient about Observation) Sept.-94 Apr-08<br />
<strong>HCH</strong>-918 Observation Status Summary Sept.-94 May-06<br />
<strong>HCH</strong>-1331 Obstetrical Discharge Summary Dec.-01 Mar-06 Gwyn Muscillo<br />
<strong>HCH</strong>-1790 Obstetrical History Questionnaire (UMG) Jan-07<br />
<strong>HCH</strong>-1957 Occupational Medicine Audiometric Screening (Occ Med/Emp Health) S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1552 Occupational Medicine Questionnaire OCC Med Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1663 Occupational Medicine Screening Physical Exam (Occ Med) S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1564 Occupational Reproductive Questionnaire OCC Med Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-2191 Occupational Therapy Assessment Oct.-09 May-10 J. Lounsbury<br />
<strong>HCH</strong>-2071 Occupational Therapy Functional Assessment (OCC Med)<br />
<strong>HCH</strong>-2253 Occupational Therapy Patient Questionnaire May-10 May-12 Sigita Banevicuis<br />
<strong>HCH</strong>-1502 Occupational Therapy Progress Note Sep-06 Jul-07 B. Boucher/Rehab<br />
<strong>HCH</strong>-2072 Occupational Therapy Task Evaluation (OCC Med) Occ Med<br />
<strong>HCH</strong>-1481 Occupational Therpay Clinic Eval Note Aug-06 B. Boucher/Rehab<br />
<strong>HCH</strong>-942 Open Heart orders FINAL Nov.-94 Dec.-05 J. LaFlamme/ K.Coyne<br />
<strong>HCH</strong>-943 Open Heart Pre-Op Orders Nov.-94 Dec.-97<br />
<strong>HCH</strong>-1109 Open Heart Surgery (Elective) Care Path Oct.-97 Oct.-99<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2306 Open Wound Care Instructions May-11<br />
Sonnenberg<br />
<strong>HCH</strong>-565 Operating Room Record (MFICU) 00-05 Jul-09<br />
<strong>HCH</strong>-1928 Ophthalmic Photography <strong>and</strong> Testing (Ophthalmology)<br />
8/3/2012 - 9:53 AM 17/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1902 Ophthalmology Consult (UMG)<br />
<strong>HCH</strong>-2256 Ophthalmology Consult (NICU) May-10 Jun-10 T. Donovan<br />
<strong>HCH</strong>-1991 Ophthalmology Encounter Note (Ophthalmology)<br />
<strong>HCH</strong>-1996 Ophthalmology Post-Operative Instructions (UMG)<br />
<strong>HCH</strong>-1997 Ophthalmology Post-Operative Instructions Spanish (UMG)<br />
<strong>HCH</strong>-1906 Ophthalmology Pre Op Cataract Surgery Summary (Ophthalmology)<br />
<strong>HCH</strong>-2263 Order Documentation Sheet Jul-10 Ute Schroeder<br />
<strong>HCH</strong>-1685 Order For Administration Of Definity Contrast Agent For Use During Transthoracic Echocardiogram 00-2005 Jul-12 Deborah Clark / Christine Burns<br />
<strong>HCH</strong>-121 Order Sheet (Automatic Stop Orders) - Order from warehouse (Moore)<br />
<strong>HCH</strong>-1938 Order Sheet (UMG)<br />
<strong>HCH</strong>-121B Order Sheet Hemodialysis St<strong>and</strong>ing Orders Apr-86<br />
<strong>HCH</strong>-1305 Orders for 2nd Trimester Termination Patients Oct.-99 Mar-06 Sue Goodrich<br />
<strong>HCH</strong>-1306 Orders for C-Section Delivery Oct.-99 Jan.-10 Sue Goodrich<br />
<strong>HCH</strong>-1598 Orthopedic Surgery H<strong>and</strong> Therapy Referal Sep-06 Oct-08 Linda Clark-UMG Clinical<br />
<strong>HCH</strong>-1792 Orthopedic Surgery Letter <strong>of</strong> Medical Necessity (UMG)<br />
Orthopedic Surgery New Patient Questionnaire (UMG)<br />
00-05 Nov-11 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-1572<br />
Jan-07 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-2310 Orthosis Examination Jul-11 Jennifer Smedberg<br />
<strong>HCH</strong>-1532 Osteoporosis Follow Up Encounter Note UMG Oct-06 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-1531 Osteoporosis New Patient or Consult H&P UMG Oct-06 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-1530 Osteoporosis New Patient Questionnaire UMG Oct-06 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-2060 Outcome <strong>of</strong> Treatment Assessment via Global Assessment <strong>of</strong> Functioning (GAF)<br />
<strong>HCH</strong>-2233 Outpatient Cardiology History & Physical Feb.-10 C. Ingriselli<br />
<strong>HCH</strong>-1431 Outpatient Database Dept. <strong>of</strong> Rehab <strong>and</strong> Sports Medicine Replaced by <strong>HCH</strong>-2249 Rehab Plan Care Aug-92 May-08 Rehab & Sports Medicine<br />
<strong>HCH</strong>-2272 Outpatient Diet Order Form Aug-10 Dr. Allen<br />
<strong>HCH</strong>-2300 Outpatient Diet Order Form - Cancer Center May-11 Apr-12 Jessie Riemer<br />
<strong>HCH</strong>-2214 Outpatient MAR- Labor & Delivery Dec.-09 Jan-10 Toni Leers<br />
<strong>HCH</strong>-1537 Outpatient Medication Administration Record Nov-06 Nov-11 Jessie Riemer<br />
<strong>HCH</strong>-1947 Outpatient Order Sheet (Psych)<br />
<strong>HCH</strong>-1426 Outpatient Progress Note Feb-06 Rehab<br />
<strong>HCH</strong>-1763 Outpatient Psychiatry AIMS Exam Procedure Dec-06 M.Kelly-Psychiatry<br />
<strong>HCH</strong>-1763A Outpatient Psychiatry AIMS Exam Procedure (blank) Dec-06 M.Kelly-Psychiatry<br />
<strong>HCH</strong>-1764 Outpatient Psychiatry Case Management Progress Note Dec-06 M.Kelly-Psychiatry<br />
<strong>HCH</strong>-1764A Outpatient Psychiatry Case Management Progress Note (blank) Dec-06 M.Kelly-Psychiatry<br />
<strong>HCH</strong>-1765 Outpatient Psychiatry Case Management Referral Form Dec-06 M.Kelly-Psychiatry<br />
<strong>HCH</strong>-1765A Outpatient Psychiatry Case Management Referral Form (blank)<br />
Outpatient Psychiatry Group Psychotherapy Progress Note<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1579<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Group Psychotherapy Progress Note (blank)<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1579A<br />
Dec-06<br />
Outpatient<br />
<strong>HCH</strong>-1933 Outpatient Psychiatry Medication Management Progress Note (Outpatient Psych)<br />
<strong>HCH</strong>-1766 Outpatient Psychiatry Mood Scale Deleted Oct 2007<br />
<strong>HCH</strong>-1766A Outpatient Psychiatry Mood Scale (blank)<br />
<strong>HCH</strong>-1932 Outpatient Psychiatry PHQ9 Scan Form (Psych Outpatient)<br />
8/3/2012 - 9:53 AM 18/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
Outpatient Psychiatry Prescription Form<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1577<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Prescription Form (blank)<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1577A<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Psychotherapy Progress Note<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1575<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Psychotherapy Progress Note (blank)<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1575A<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Risk Screen<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1576<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Risk Screen (blank)<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1576A<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Treatment Plan<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1574<br />
Dec-06<br />
Outpatient<br />
Outpatient Psychiatry Treatment Plan (blank)<br />
Martin Kelly-Psychiatry<br />
<strong>HCH</strong>-1574A<br />
Dec-06<br />
Outpatient<br />
<strong>HCH</strong>-1493 Outside Allergy Injection Order UMG Aug-06 E. Wagner<br />
<strong>HCH</strong>-1026 Ovarian Hyperstimulation Syndrome Care Plan Sept.-96<br />
<strong>HCH</strong>-1832 Pacemaker Care <strong>and</strong> Patient Discharge Instructions<br />
<strong>HCH</strong>-682 Pain Assessment Scale Aug.-92 Oct.08 NICU/NBN<br />
<strong>HCH</strong>-2297 Pain Assessment Scale - Neonatal Infant Pain Scale (NIPS) Feb-11 Terry Donovan<br />
<strong>HCH</strong>-1458 Pain Level Documentation May-06 Mar-07 Nursing Psych.<br />
<strong>HCH</strong>-1320 Pain Progress Note (JDH) Aug.-00 Sue Goodrich<br />
<strong>HCH</strong>-1742 Pamidronate Disodium Pre-Printed Order Set Dec-06 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-1750 Pamidronate Disodium Pre-Printed Order Set - Paget's Disease<br />
<strong>HCH</strong>-1896 PAP Tracking Flowsheet (Ob/GYN)<br />
<strong>HCH</strong>-1779 Parenteral Pain Medication Order Sheet Jan-07<br />
<strong>HCH</strong>-1880 Partial Hospital <strong>and</strong> Intensive Outpatient Admission Safety Plan (Psychiatry)<br />
<strong>HCH</strong>-1876 Partial Hospital Intensive Outpatient Program Checklist (Dept <strong>of</strong> Psychiatry) 00-05 Aug-10 Sigita Banevicius<br />
<strong>HCH</strong>-1882 Partial Hospital Program 18th Day Recertification (Psychiatry) Mar-06 Sep-11 Alexis Guarino/J. Lounsbury<br />
<strong>HCH</strong>-1883 Partial Hospital Program 30 Day Recertification (Psychiatry) Mar-06 Sep-11 Alexis Guarino/J. Lounsbury<br />
<strong>HCH</strong>-1881 Partial Hospital Program Admission Certification (Psychiatry) Mar-06 Sep-11 Alexis Guarino/J. Lounsbury<br />
<strong>HCH</strong>-1889 Partial Hospital Program <strong>and</strong> Intensive Outpatient Orientation System Checklist<br />
<strong>HCH</strong>-2179 Partial Hospital Program/Intensive Outpatient Program Group Note REPLACED BY <strong>HCH</strong>-2351 Oct.-09 Oct-11 S. Richmond/S. Banevicius<br />
<strong>HCH</strong>-1143 Patch Testing Order Sheet Nov.-97 Aug.-98<br />
<strong>HCH</strong>-2319 Patient <strong>and</strong> Family Education Record - Initial Learning Assessment Nov-11 Jessie Riemer<br />
<strong>HCH</strong>-2327 Patient <strong>and</strong> Family Education Record - On-Going Assessment Nov-11 Jessie Riemer<br />
<strong>HCH</strong>-1736 Patient <strong>and</strong> Family Educ Record Learning Assessment Cancer Center REPLACED BY <strong>HCH</strong>-2319 & <strong>HCH</strong>-2327<br />
<strong>HCH</strong>-1058 Patient <strong>and</strong> Family Teaching Record Acute MI Sept.-97 Sept.-00<br />
<strong>HCH</strong>-1220 Patient <strong>and</strong> Family Teaching Record - Ambulatory Surgery Sept.-98 00-00<br />
<strong>HCH</strong>-1376 Patient <strong>and</strong> Family Teaching Record Antepartum Dec.-06 Feb.-10 Sue Goodrich<br />
<strong>HCH</strong>-1216 Patient <strong>and</strong> Family Teaching Record Anticoagulation Med Compliance Sept.-98 00-00<br />
<strong>HCH</strong>-1221 Patient <strong>and</strong> Family Teaching Record Breast Biopsy Sept.-98 Sept.-00<br />
<strong>HCH</strong>-2146 NO LONGER A CHART FORM Patient <strong>and</strong> Family Teaching Record Button Gastrostomy (NICU) DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1317 Patient <strong>and</strong> Family Teaching Record Cardiac Stepdown May-00 Aug.-00<br />
<strong>HCH</strong>-1222 Patient <strong>and</strong> Family Teaching Record Cataract Surgery Sept.-98 Sept. -00<br />
<strong>HCH</strong>-1242 Patient <strong>and</strong> Family Teaching Record Congestive Heart Failure Oct.-98<br />
<strong>HCH</strong>-1226 Patient <strong>and</strong> Family Teaching Record ENT Mouth Surgery Sept.-98 Sept.-00<br />
<strong>HCH</strong>-1230 Patient <strong>and</strong> Family Teaching Record ENT Neck Surgery Sept.-98 Sept.-00<br />
8/3/2012 - 9:53 AM 19/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1246 Patient <strong>and</strong> Family Teaching Record - Epilepsy Monitoring Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1128 Patient <strong>and</strong> Family Teaching Record General Surgery<br />
<strong>HCH</strong>-1224 Patient <strong>and</strong> Family Teaching Record Herniorrhaphy Sept.-98 Sept.-00<br />
<strong>HCH</strong>-1375 Patient <strong>and</strong> Family Teaching Record Intrapartum/Post Partum 00-00 Dec-11 Sue Goodrich<br />
<strong>HCH</strong>-1377 Patient <strong>and</strong> Family Teaching Record Newborn<br />
<strong>HCH</strong>-1223 Patient <strong>and</strong> Family Teaching Record Oral <strong>and</strong> Dental Surgery Sept.-98 Sept.-00 J. Lounsbury<br />
<strong>HCH</strong>-1247 Patient <strong>and</strong> Family Teaching Record - Ostomy Teaching Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1241 Patient <strong>and</strong> Family Teaching Record - Ovarian Hyperstimulation Oct.-98 Sept.-00<br />
<strong>HCH</strong>-1218 Patient <strong>and</strong> Family Teaching Record Port Cath Placement Sept.-98 Sept.-00<br />
<strong>HCH</strong>-1225 Patient <strong>and</strong> Family Teaching Record Port Cath Placement Sept.-98 Sept.-00<br />
<strong>HCH</strong>-1248 Patient <strong>and</strong> Family Teaching Record - Stroke Teaching Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1227 Patient <strong>and</strong> Family Teaching Record Tonsillectomy Adenoidectomy Sept.-98 Sept.-00<br />
<strong>HCH</strong>-1228 Patient <strong>and</strong> Family Teaching Record Tympanoplasty Sept-.98 Sept.-00<br />
<strong>HCH</strong>-1229 Patient <strong>and</strong> Family Teaching Record Vein Ligation Stripping Sept.-98 Sept.-00<br />
<strong>HCH</strong>-2005 Patient Care Plan 00-05 Nov-10 Nursing<br />
<strong>HCH</strong>-867 Patient Controlled Analgesia Orders Feb.-94 Feb-.06 Anesthesiology<br />
<strong>HCH</strong>-1347 Patient Debriefing on Restraint Seclusion Nov-02 Sep-09<br />
<strong>HCH</strong>-1520 Patient Encounter Note - UMG Oct-06 UMG<br />
<strong>HCH</strong>-2059 Patient Health Questionnaire 9 (PHP)<br />
<strong>HCH</strong>-2157 Patient Health Questionnaire 9 (Psychiatry) Apr-09 Jun-09 Susan Richmond<br />
<strong>HCH</strong>-1314 Patient Information Sheet - Radiation Oncology Jan.-00 Sept.-09 Radiation Oncology<br />
<strong>HCH</strong>-2381 Patient Instructions - Chemical Peels (Superficial <strong>and</strong> Medium Depth) Post-Procedure Care Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2382 Patient Instructions - Chemical Peels (Superficial <strong>and</strong> Medium Depth) Pre-Procedure Instructions Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1937 Patient Instructions - Medication Dosing Schedule (UMG)<br />
<strong>HCH</strong>-1956 Patient Instructions - Ophthalmology Pre-Operative (Ophthalmology)<br />
<strong>HCH</strong>-2383 Patient Instructions - Photodynamic Therapy Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1260 Patient Instructions Geriatrics (UMG) Nov.-98 Jan.-07<br />
<strong>HCH</strong>-2128 Patient Intake Form Cardiology-Pulmonary Apr-09 Nov.-09<br />
<strong>HCH</strong>-1437 Patient Intake Sheet (UMG) Mar-06 Ute Schroeder-GI<br />
<strong>HCH</strong>-2265 Patient Medical History Aug-10 Linda Manzelli<br />
<strong>HCH</strong>-2144 Patient On Treatment Visit Note (Rad Onc)<br />
<strong>HCH</strong>-2136 Patient Planning Information - Rad Onc May-09 Nov.-09 Debra Litke-Rad Oncology<br />
<strong>HCH</strong>-1545 Patient Questionnaire - Electric Boat OCC MED Nov-06 S. Barnosky -Occ Med<br />
<strong>HCH</strong>-1777 Patient Questionnaire - Back Pain Follow Up (UMG OCC MED/Emp Hlth) Jan-07 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1549 Patient Questionnaire - Hearing Loss OCC Med Emp Health Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-1893 Patient Questionnaire - Indoor Environmental Quality <strong>and</strong> Health (Occ Med)<br />
<strong>HCH</strong>-1909 Patient Questionnaire Cumulative Trauma Disorders Upper Extremities (Occ Med)<br />
<strong>HCH</strong>-1998 Patient Questionnaire -Dermal Filler (Derm)<br />
<strong>HCH</strong>-1927 Patient Questionnaire International Prostate Symptom Score (Urology)<br />
<strong>HCH</strong>-1907 Patient Questionnaire Musician's Clinic (Occ Med)<br />
<strong>HCH</strong>-1929 Patient Questionnaire Pelvic Floor Impact (Urology)<br />
<strong>HCH</strong>-1553 Patient Questionnaire Pre Placement Exam OCC Med/Emp Health Dec-06 S.Barnosky - Occ Med<br />
<strong>HCH</strong>-2006 Patient Questionnaire PHYSIATRY HISTORY & TREATMENT POST SURG (ortho)<br />
<strong>HCH</strong>-2257 Patient Questionnaire for Speech Therapy Jun-10 Barbara Boucher-Rehab<br />
<strong>HCH</strong>-1884 Patient Rights Information (Psychiatry)<br />
<strong>HCH</strong>-2244 Patient Transfer H<strong>and</strong>-Off Communication Form (ISBAR) L&D/OB Gyn-Postpartum Apr-10 Sue Goodrich<br />
<strong>HCH</strong>-1345 Patient's Property Valuables/Transfer/Discharge Feb-98 Apr-12 Nursing / Dananne Vibert<br />
<strong>HCH</strong>-1555 Peak Flow Chart - Patient Reported OCC Med Employee Health Dec-06 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1887 Pediatric Ambulatory Surgery Discharge Instructions (FSC)<br />
8/3/2012 - 9:53 AM 20/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1905 Pelvic Floor Distress Questionnaire (Urology)<br />
<strong>HCH</strong>-1407 Percutaneous Thrombolysis Apr-05<br />
<strong>HCH</strong>-2083 Perinatal Lactation Record<br />
<strong>HCH</strong>-1654 Periodic Asbestos Patient Questionnaire (UMG Occ Med) Feb-07 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1550 Periodic Respirator Questionnaire Employee Health Dec-06 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-2046 NO LONGER A CHART FORM Peripherally Inserted PICC Insertion <strong>and</strong> Maintenance (NICU) DEACTIVATED 10/2011<br />
<strong>HCH</strong>-628 Peritoneal Dialysis Flowsheet Jun-92 Apr-06<br />
<strong>HCH</strong>-129 Permission for Autopsy Jan-02 K. Coyne<br />
<strong>HCH</strong>-1003 NO LONGER A CHART FORM Permission for Independent Gr<strong>and</strong>parent Visitation DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1397 Permission to Communicate with Family <strong>and</strong> or Others Involved in your care Nov.-05 Mar-11 Carlene Bartolotta<br />
<strong>HCH</strong>-901 Permission to Treat Consent Apr-03 Apr-11<br />
<strong>HCH</strong>-2194 Permission to Treat Consent (Spanish) Nov.-09 C. Schramm<br />
<strong>HCH</strong>-2195 Permission to Treat Consent (Polish) Nov.-09 C. Schramm<br />
<strong>HCH</strong>-2196 Permission to Treat Consent (CDOC) Spanish Nov.-09 C. Schramm<br />
<strong>HCH</strong>-2197 Permission to Treat Consent (CDOC) Polish Nov.-09 C. Schramm<br />
<strong>HCH</strong>-447 Permisson for Body Release Feb.-77 Feb.-02 Nursing<br />
<strong>HCH</strong>-717 Permit for Release <strong>of</strong> Infant to Person Other Than Parent Nov.-92 Sep-11 Nursing<br />
<strong>HCH</strong>-1164 Personal Property Release (DISCONTINUED) Replaced by <strong>HCH</strong>1345 Feb.-98 Apr-06<br />
<strong>HCH</strong>-2209 PET Scan Requisition (Moore Form) Dec.-09 S. Hensel<br />
<strong>HCH</strong>-1743 Phelbotomy Pre-Printed Order Set Dec-06 Dec-11 Jessie Riemer<br />
<strong>HCH</strong>-2119 PHP/IOP Admission Database 00-00 Apr-10 Sue Richmond<br />
<strong>HCH</strong>-2056 PHP/IOP Daily Patient Self Questionnaire<br />
<strong>HCH</strong>-2055 PHP/IOP Daily Suicidal/Homicidal Ideation Risk Assessment<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2343 Phototherapy Instructions Dec-11<br />
Sonnenberg<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2333 Phototherapy Treatment Flowsheet Nov-11 Dec-11 Sonnenberg<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2240 Phototherapy Treatment Flowsheet-UVA-PUVA Mar-10 Dec-11 Sonnenberg<br />
<strong>HCH</strong>-2239 Phototherapy Treatment Flowsheet-UVB Narrowb<strong>and</strong> Mar-10 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1533 Physiatry Encounter Note UMG Oct-06 K. Clarke<br />
<strong>HCH</strong>-2199 Physiatry New Patient Questionnaire Intake Form Oct.-09 Kelly Clarke/Rheum/Osteo<br />
<strong>HCH</strong>-1741 Physiatry Patient Questionnaire - UMG Nov-06 Oct-09 Orthopaedic Surgery-K.Clarke<br />
<strong>HCH</strong>-2201 Physiatry Preprocedural Requisition Nov.-09 Kelly Clarke<br />
<strong>HCH</strong>-2198 Physiatry Spine Follow Up Questionnaire Nov.-09 Kelly Clarke<br />
<strong>HCH</strong>-1485 Physical Therapy Evaluation Aug-06 B.Boucher-Rehab<br />
<strong>HCH</strong>-1412 Physician Communication Sep-05 Rehab Dept.<br />
<strong>HCH</strong>-1292 Physician Orders Venous Thrombosis Jun-99<br />
<strong>HCH</strong>-677 Physician Postoperative/Post Procedure Note Aug.-92 Aug.-06<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2314 Pigmented Lesion Post-Treatment Instructions Aug-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1760 Plan <strong>of</strong> Care - Speech Pathology Dec-06 Apr-07 E.Wagner- Otolaryngology<br />
<strong>HCH</strong>-2137 Planning Directive - Rad Onc May-09 Nov.-09 Debra Litke-Rad Oncology<br />
<strong>HCH</strong>-1492 Plasmapheresis Progress Note Mar-06<br />
<strong>HCH</strong>-1210 Plasmapheresis St<strong>and</strong>ing Order Jan.-99 Mar-06<br />
<strong>HCH</strong>-1254 Pneumocystis Carinii Pneumonia (PCP) Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1213 Pneumocystis Carinii Pneumonia Care Path Sept.-98 00-00<br />
<strong>HCH</strong>-1153 Pneumocystis Carinii Pneumonia Care Path Orders - Admission<br />
8/3/2012 - 9:53 AM 21/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1249 Patient <strong>and</strong> Family Teaching Record - Pneumonia Community Acquired Oct.-98 Dec.-00<br />
<strong>HCH</strong>-1154 Pneymocystis Carinii Pneumonia Care Path Dec.-1997<br />
<strong>HCH</strong>-1507 Post Amniocentesis Instructions & Precautions Oct-06 Nancy Maxwell/OB GYN<br />
<strong>HCH</strong>-977 Post Angioplasty Recovery Record Oct.-95<br />
<strong>HCH</strong>-899 Order Sheet -B1015Post Cardiac Catheterization Orders Jul-94 Nov.-09 Cardiology<br />
<strong>HCH</strong>-1506 Post Chorionic Villus Sampling (CVS) Instructions & Precautions Oct-06 Nancy Maxwell/OB GYN<br />
<strong>HCH</strong>-941 Post ICU Cardiac Surgery Orders Nov.-94 Aug-00<br />
<strong>HCH</strong>-2114 Post Op Back Database (PT)<br />
<strong>HCH</strong>-2115 Post Op Back Evaluation (PT)<br />
<strong>HCH</strong>-2113 Post Op Back Patient Education (PT)<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2315 Post Peel Instructions Aug-11<br />
Sonnenberg<br />
<strong>HCH</strong>-876 Post PICC Line Insertion Orders Aug.-94 Oct.-06 Radiology<br />
<strong>HCH</strong>-2129 Post Procedure Follow Up Telephone Call (Derm)<br />
<strong>HCH</strong>-1103 Post-Operative Total Hip Arthroplasty Orders Oct.-97 Apr-06<br />
<strong>HCH</strong>-1104 Post-Operative Total Knee Arthroplasty Orders Oct.-97 Oct.-00<br />
<strong>HCH</strong>-626 Postpartum/GYN Flowsheet Mar-92 Nov.-07 Nursing<br />
<strong>HCH</strong>-1488 Postpartum Visit Note Jul-06 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-1385 Postprocedural Abdominoplasty Orders Jun-04 Dec.-05 C.Schramm<br />
<strong>HCH</strong>-1387 Postprocedural Facelift Orders Jun-04 Nov.-05 C.Schramm<br />
<strong>HCH</strong>-1386 Postprocedural Mammaplasty Reduction Orders May-04 Nov.-05 C.Schramm<br />
<strong>HCH</strong>-2288 Post Visit Phone Call for Inpatients Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2294 Post Visit Phone Call for Inpatients (OB/GYN) Feb-11 G. Muscillo<br />
<strong>HCH</strong>-1451 Pre ECT History <strong>and</strong> Physical (Replaced by <strong>HCH</strong>-2250 Pre-Op History & Physical Exam) Apr-06 Psych-ECT<br />
<strong>HCH</strong>-1491 Pre-Allergy Testing Screening UMG Jul-06 E.Wagner<br />
<strong>HCH</strong>-2269 Pre-Anesthesia Assessment Form (Moore Form) Aug-10 C.Schramm<br />
<strong>HCH</strong>-1349 Pre-Cardiac Catheterization Angioplasty Orders (Cardiac Cath Lab) Mar-03 Jul-07 Jean Bodett-Cardiac Cath.<br />
<strong>HCH</strong>-2308 Pre-discharge Assessment for the Risk <strong>of</strong> Hyperbilirubinemia in Infants ≥ 35 Weeks Gestation Jun-11 Terese Donovan<br />
<strong>HCH</strong>-2384 Prednisone Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1878 Pre-Electroconvulsive Therapy Nursing Assessment (ECT) 00-00 Sep-10<br />
<strong>HCH</strong>-2250 Pre-Op History <strong>and</strong> Physical Exam-ECT May-10 J.Condon<br />
<strong>HCH</strong>-2277 Pre-Procedure Checklist for In-House Transport <strong>of</strong> Infants to Areas Other thatn the OR Oct-10 Terese Donovan<br />
<strong>HCH</strong>-1470 Pregnancy Diabetic Care Flowsheet Jun-06 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-1955 Pregnancy Release (Diagnostic Imaging)<br />
<strong>HCH</strong>-1802 Prenatal Flow Sheet (UMG OB/GYN) Apr-07 Feb-11 Ute Schroeder<br />
<strong>HCH</strong>-2074 Preoperative Arthroplasty Orders Jul-08 Jun-12 Carol Schramm<br />
<strong>HCH</strong>-964 Pre-Op History <strong>and</strong> Physical Exam Sep-95 Mar-12 Carol Schramm<br />
<strong>HCH</strong>-995 Pre-Operative Total Joint Orders Feb.-96 Mar-06<br />
<strong>HCH</strong>-961 Pre-percutaneous Coronary Angioplasty Mar-95 Apr-06 Cardiology<br />
<strong>HCH</strong>-1871 Preoperative/Preprocedure Orders B1051 Jul-07 Jun-12 Carol Schramm<br />
<strong>HCH</strong>-1110 Prescription Telephone Refill Sheet Oct.-97 May-06<br />
<strong>HCH</strong>-1534 Pre-Travel Encounter Note UMG Oct-06<br />
<strong>HCH</strong>-1521 Prevention/Health Promotion Flow Sheet UMG Jan-02 UMG- Clinical Informatics<br />
<strong>HCH</strong>-1478 Problem <strong>List</strong> UMG Jun-00 Linda Clark/UMG<br />
<strong>HCH</strong>-1511 Procedure Note Colposcopy <strong>and</strong> LEEP 00-05 Oct-06 N. Maxwell OB/GYN<br />
<strong>HCH</strong>-2143 Procedure Note Stereoscopic X-Ray Guidance (Rad Onc)<br />
<strong>HCH</strong>-1474 Procedure Scheduling Checklist MFM OB GYN Jul-06 Nancy Maxwell/OB GYN<br />
<strong>HCH</strong>-1484 Progress Note OT Total Hip Arthroplasty Aug-06 B.Boucher-Rehab<br />
<strong>HCH</strong>-1974 NO LONGER A CHART FORM Progress Note/Treatment Plan Update - Nursing (Psych) Deactivated 9/09<br />
8/3/2012 - 9:53 AM 22/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1973 NO LONGER A CHART FORM Progress Note/Treatment Plan Update Occ Therapy (Psych) Deactivated 9/09<br />
<strong>HCH</strong>-1972 NO LONGER A CHART FORM Progress Note/Treatment Plan Update - Social Worker (Psych ) Deactivated 9/09<br />
<strong>HCH</strong>-1971 NO LONGER A CHART FORM Progress Note/Treatment Plan Update-Substance Abuse Counselor (Psych) Deactivated 9/09<br />
<strong>HCH</strong>-1425 Daily Progress Note-<strong>Department</strong> <strong>of</strong> Rehab <strong>and</strong> Sports Medicine Nov-05 Jul-09 Rehab<br />
<strong>HCH</strong>-1355A Protected Health Information Disclosure Tracking Log Newborn Apr-03 Sep-11 I. Mauriello-Compliance<br />
<strong>HCH</strong>-1355 Protected Health Information Disclosure Tracking Log-HIPAA<br />
<strong>HCH</strong>-2220 Psoralen Ultra Uva (Oral Puva) Phototherapy Order Sheet Nov.-09 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-2218 Psoralen Ultra Uva (Puva Soak) Phototherapy Order Sheet Dec.-09 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-2219 Psoralen Ultra Uva (Topical Puva) Phototherapy Order Sheet Dec.-09 Jan.-10 Sue Marcella<br />
<strong>HCH</strong>-1986 Psorahen + Ultraviolet (PUVA) Topical Soak Orders (Dermatology)<br />
<strong>HCH</strong>-1787 Psoralen Ultraviolet A Light Therapy (PUVA) Informed Consent (UMG) Jan-07 Dermatology<br />
<strong>HCH</strong>-1788 Psoralen Ultraviolet A Light Therapy (PUVA) Provider Corresp (UMG) Jan-07 Dermatology<br />
<strong>HCH</strong>-1865 Psych Inpatient Admission Personal Pr<strong>of</strong>ile<br />
<strong>HCH</strong>-1866 Psych/Alcohol/Opiate Detoxification Inpatient Unit Order Sheet<br />
<strong>HCH</strong>-1092 Psychiatric Inpatient Unit Sept.-97 Dec.-00<br />
<strong>HCH</strong>-886 Psychiatric Inpatient Unit Admission Orders (Inpt Psych) 00-05 Jun-08 Nursing<br />
<strong>HCH</strong>-1886 Psychiatric Medication Pharmacy Call Sheet (Dept <strong>of</strong> Psychiatry)<br />
<strong>HCH</strong>-584 Psychiatric Nursing Flow Sheet (Dept <strong>of</strong> Psychiatry) Dec.-90 Jun-10 J. Lounsbury<br />
<strong>HCH</strong>-2027 Psychiatric Occupational Therapy Re-Admission Evaluation (Rehab)<br />
<strong>HCH</strong>-1879 Psychiatric Partial <strong>and</strong> Intensive Outpatient Telephone Assessment (Psychiatry)<br />
<strong>HCH</strong>-2355 Psychosocial Distress Screening Jun-12 S<strong>and</strong>ra Watcke<br />
<strong>HCH</strong>-1360 Pulmonary Arterial Hypertension Admission Orders Jun-03 Jan-11 Julie Laflamme<br />
<strong>HCH</strong>-930 Pulmonary Laboratory Testing Request May-94 Feb-12 Nancy McLellan, Pulmonary Lab<br />
<strong>HCH</strong>-1398 Pulmonary Pre-Printed Perioperative Nursing Care Orders (Periop Nursing) Oct.-04 Nov.-09 C. Schramm<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2317 QuadraLase Post Care Instructions Aug-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1648 RabAvert Rabies Vaccine Post Exposure Immuniz (UMG Occ Med/Emp Hlth) Feb-07 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1647 RabAvert Rabies Vaccine Pre Exposure Immuniz (UMG Occ Med/Emp Hlth) Jan-07 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1295 Radiation Oncology Database Sept.-99 Feb.-06<br />
<strong>HCH</strong>-1231 Radiation Therapy Treatment Site Abdomen Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1232 Radiation Therapy Treatment Site Breast Chest Wall Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1233 Radiation Therapy Treatment Site CNS Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1234 Radiation Therapy Treatment Site General Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1235 Radiation Therapy Treatment Site Head <strong>and</strong> Neck Oct.-98 Aug.-00 Labor/Delivery G. Muscillo<br />
<strong>HCH</strong>-1236 Radiation Therapy Treatment Site Pelvis Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1238 Radiation Therapy Treatment Site Thorax Oct.-98 Aug.-00<br />
<strong>HCH</strong>-1237 Radiation Therapy Treatment to the Head with Screws Oct.-98 Aug.-00<br />
<strong>HCH</strong>-2183 Rapid Response Team Record Nov-05 Oct-11 J. LaFlamme/ K.Coyne<br />
<strong>HCH</strong>-2009 Reclast Orders for Osteoporosis (Osteo UMG) Jan-08 Nov-10 K. Clarke<br />
<strong>HCH</strong>-2291 Rehab Daily Note Dec-10 Mar-11 Morgan Hills<br />
<strong>HCH</strong>-2007 Reclast Orders for Paget's (Osteo Clinic UMG) Jan-08 Dec-10 Jessie Riemer<br />
<strong>HCH</strong>-2172 Recovery Record (Labor <strong>and</strong> Delivery/PACU) Sept.-09 Jan-12 G. Muscillo / SueEllen Goodrich<br />
<strong>HCH</strong>-2008 Re-Evaluation Form Neurosurg/Comprehensive Spine Center (UMG)<br />
<strong>HCH</strong>-1557 Referral Fitness for Duty Evaluation OCC Med Employee Health Dec-06 S.Barnosky/Occ Med<br />
<strong>HCH</strong>-1829 Reflux Findings Score Sheet (UMG Otolaryngology)<br />
<strong>HCH</strong>-1806 Refractive Surgery Consent (UMG)<br />
<strong>HCH</strong>-934 Refusal <strong>of</strong> Blood <strong>and</strong> or Blood products 00-0000 Apr-06<br />
8/3/2012 - 9:53 AM 23/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-2356 Refusal <strong>of</strong> Treatment/Service/Procedure Form Jun-12 Deborah Bugryn<br />
<strong>HCH</strong>-2149 Regional Anesthesia Record (Anesthesia) Jun-09 Jun-11 Carol Schramm<br />
<strong>HCH</strong>-1543 Registration Questionnaire UMG (Taste <strong>and</strong> Smell) Nov-05 M. Woodward<br />
<strong>HCH</strong>-1423 REHAB Daily Progess Note Nov-05 Jul-09 Rehab<br />
<strong>HCH</strong>-1504 Rehab Flow Sheet Aug-06 May-10 B. Boucher- Rehab<br />
<strong>HCH</strong>-1422 Rehabilitation Services Discharge Summary Nov-05 Oct-10 B. Boucher-Rehab<br />
<strong>HCH</strong>-1486 Rehab Patient Questionnaire Aug-06 B.Boucher-Rehab<br />
<strong>HCH</strong>-2249 Rehab Plan <strong>of</strong> Care May-10 B.Boucher-Rehab<br />
<strong>HCH</strong>-2252 Rehab Progress Note May-10 B.Boucher-Rehab<br />
<strong>HCH</strong>-1424 Rehab Re-Evaluation Nov-05 Rehab<br />
<strong>HCH</strong>-46A Rehabilitation Referral Dec-93 Jul-05 B.Boucher-Rehab. Services<br />
<strong>HCH</strong>-444 Release Form for Blood Components Sept.-96 May-05<br />
<strong>HCH</strong>-2385 Remicade (Infliximab) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1797 Remote Transmission Reviewed Mar-07 Cardiology<br />
<strong>HCH</strong>-2353 Renal Biopsy Order Set Apr-12 Jessie Riemer<br />
<strong>HCH</strong>-1353 Request for Accounting <strong>of</strong> Disclosures <strong>of</strong> Protected Health Information Apr-03 I.Mauriello-Compliance<br />
<strong>HCH</strong>-1352 Request for Amendment <strong>of</strong> Health Information HIPAA Apr-03 Jun-12 I.Mauriello-Compliance<br />
<strong>HCH</strong>-1539 Request For Electrodiagnostic Testing Oct-06 Nov.-09 Orthopaedic Surgery<br />
<strong>HCH</strong>-1037 Request for Neurophysiologic Testing Apr-97 Sept.-09 Neurology<br />
<strong>HCH</strong>-1351 Request to Review Record/Notification <strong>of</strong> Approval or Denial To View Apr-03 Apr-11 I.Mauriello-Compliance<br />
<strong>HCH</strong>-852A Resident Database/Initial Evaluation (Psychiatry Inpatient) DEACTIVATED 5/2012 Apr-04 Mar-08 Nursing/Psych.<br />
<strong>HCH</strong>-1450 Resident Fellow Patient Encounter Form Sept.-98 Apr-06 M.Hein-UMG<br />
<strong>HCH</strong>-1848 Respirator Medical Evaluation Questionnaire OCC Med Emp Health<br />
<strong>HCH</strong>-1563 Respirator Medical Evaluation Questionnaire OCC Med Emp Health-Deleted Use <strong>HCH</strong>1848 Dec-06 S.Barnosky- Occ Med<br />
<strong>HCH</strong>-804 Respiratory Care Treatment Record Sept.-95 May-06 Resp. Care<br />
<strong>HCH</strong>-1739 NO LONGER A CHART FORM Respiratory Ventilator Sheets DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1269 Restraint 1:1& Constant Observ.Flowsheet Acute Medical SurgicalReplaced by <strong>HCH</strong>2287<br />
<strong>HCH</strong>-2287 Restraint Monitoring/Observation (CO 1:1 Status) 15 minute Checklist Flowsheet Dec-10 May-12 Am<strong>and</strong>a Darcy<br />
<strong>HCH</strong>-1992 Retinal Drawing (Ophthalmology)<br />
<strong>HCH</strong>-1459 Return to Work or School - UMG<br />
<strong>HCH</strong>-1657 Return to Work Recommendations (UMG OCC MED/Emp Hlth)<br />
<strong>HCH</strong>-1560 Review <strong>of</strong> Tuberculosis Symptoms OCC Med Employee Health Dec-06 Feb-11 Janet Pinto OCC MED<br />
OB/GYN G. Muscillo/Kelly<br />
<strong>HCH</strong>-1529 Rheumatology New Patient Questionnaire UMG Sep-09 May-11 Clarke<br />
<strong>HCH</strong>-2047 Rheumatology Osteo Infliximab Pre-Printed Order Set<br />
<strong>HCH</strong>-1778 Risks <strong>and</strong> Benefits Consent Form (UMG Dermatology) Jan-07 S.Barnosky/OccMed<br />
<strong>HCH</strong>-764 Routine Newborn Orders - Newborn Nursery Apr-93 Apr-07 NICU/NBN<br />
<strong>HCH</strong>-2298 RN Visit - Sickle Cell Pain Apr-11 J. Riemer<br />
<strong>HCH</strong>-1056 Rule Out MI Orders Aug.-97<br />
<strong>HCH</strong>-1930 Sample Medication Patient Instructions (UMG)<br />
<strong>HCH</strong>-2174 Scheduled C-Section Flowsheet - Pre - Op Sept.-09<br />
<strong>HCH</strong>-1793 Scleroderma/CREST Test Schedule Instructions (Rheumatology)<br />
<strong>HCH</strong>-2386 Sclerotherapy Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-875 SCO Myocardial Infarction Nov.-94 ICU<br />
<strong>HCH</strong>-699 NO LONGER A CHART FORM SCP Care <strong>of</strong> Growing Preemie DEACTIVATED 10/2011<br />
<strong>HCH</strong>-701 NO LONGER A CHART FORM SCP Care <strong>of</strong> Infant with Diaphgagmatic Hernia DEACTIVATED 10/2011<br />
<strong>HCH</strong>-704 NO LONGER A CHART FORM SCP Care <strong>of</strong> Infant with Myelomeningocele DEACTIVATED 10/2011<br />
<strong>HCH</strong>-703 NO LONGER A CHART FORM SCP Care <strong>of</strong> Infant with Necrotizing Enterocolitis DEACTIVATED 10/2011<br />
<strong>HCH</strong>-707 NO LONGER A CHART FORM SCP Care <strong>of</strong> Infant with Perinatal Asphyxia DEACTIVATED 10/2011<br />
8/3/2012 - 9:53 AM 24/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-698 NO LONGER A CHART FORM SCP Care <strong>of</strong> Infant with Respiratory Distress DEACTIVATED 10/2011<br />
<strong>HCH</strong>-2171 SCP Care <strong>of</strong> Patient Admitted to OB/GYN HYSTERECTOMY Feb-96 Jan-10<br />
<strong>HCH</strong>-2225 SCP Cerclage Placement/Removal Jan.-2010 Sue Goodrich<br />
<strong>HCH</strong>-839 SCP Craniotomy<br />
<strong>HCH</strong>-696 NO LONGER A CHART FORM SCP For Bowel Obstruction/Abdominal Wall Defect (NICU/NBN) DEACTIVATED 10/2011<br />
<strong>HCH</strong>-883 SCP For Hypertensive Disorders Antepartum Jul-94<br />
<strong>HCH</strong>-846 SCP For Premature Rupture <strong>of</strong> Membranes Jun-94 Aug-11 Sue Goodrich<br />
<strong>HCH</strong>-833 SCP For Preterm Labor: Antepartum Patient Apr-94 Sep-10 Sue Goodrich<br />
<strong>HCH</strong>-953 SCP For Prostagl<strong>and</strong>in Termination <strong>of</strong> Pregnancy Mar-95 Oct.-09 S. Goodrich<br />
<strong>HCH</strong>-739 SCP For Respiratory Compromise Dec-89 Jan-00 ICU/Med-Surgery<br />
<strong>HCH</strong>-800 SCP Imparied Neurological Function<br />
<strong>HCH</strong>-700 SCP Newborn Nursery Mar-91 Sep-11 Terry Donovan<br />
<strong>HCH</strong>-966 SCP PTCA Aug.-95<br />
<strong>HCH</strong>-2270 Screening Criteria for TDAP (Tetanus, Diphtheria, & Pertussis) Aug-10 Jan-11 Sue Goodrich/Patty Tracey<br />
<strong>HCH</strong>-1283 Screening Questionaire for Natural Rubber Latex Sensitivity Mar-99 Apr-06<br />
<strong>HCH</strong>-722 Second Trimester Induction Flow Sheet Dec.-92 Apr-08 Nursing<br />
<strong>HCH</strong>-1303 Second Trimester Termination <strong>of</strong> Pregnancy Care Path Oct-99 Sep-09 Labor & Delivery- S.Goodrich<br />
<strong>HCH</strong>-1108 Seizures Oct.-97 Dec.-00<br />
<strong>HCH</strong>-1245 Patient <strong>and</strong> Family Teaching Record - Self Catheterization Oct.-98 Dec.-00<br />
<strong>HCH</strong>-2255 Sensory Modulation Screening Tool May-10 Sigita Banevicius<br />
<strong>HCH</strong>-508 Short Stay Discharge Summary May-89 Nov.-09<br />
<strong>HCH</strong>-1429 Shoulder Evaluation Feb-06 Rehab<br />
<strong>HCH</strong>-1361 NO LONGER A CHART FORM Sibling Visitation Screening for Infection Control DEACTIVATED 10/2011<br />
<strong>HCH</strong>-2228 Signature Identification Sheet Jan.-10 Aug-10 J. Lounsbury<br />
<strong>HCH</strong>-1498 Six Minute Walk Test (Pulmonary Lab) Sep-06 N. Mclellan/Pulmonary Lab<br />
<strong>HCH</strong>-2159 Skin <strong>and</strong> Wound Assessment Flowsheet<br />
Alexis Guarino/Karen Usala-<br />
<strong>HCH</strong>-2323 Skin <strong>and</strong> Wound Assessment Flowsheet NO LONGER IN USE Oct-11 May-12 Piteo<br />
<strong>HCH</strong>-2258 Skin Assessment Form Jun-10 Jessie Condon<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2307 Skin Graft Care Instructions May-11 Dec-11 Sonnenberg<br />
<strong>HCH</strong>-578 Skin Test Administration <strong>and</strong> Results Aug-09 Psych Sue Richmond<br />
<strong>HCH</strong>-1920 Sleep Diary (Sleep Disorders Center) Aug-09 Psych Sue Richmond<br />
<strong>HCH</strong>-1044 Sleep Laboratory Request Form May-97 May-07<br />
<strong>HCH</strong>-1921 Sleep Questionnaire (Sleep Disorders Center)<br />
<strong>HCH</strong>-1922 Sleep Study Work Form (Sleep Disorders Center)<br />
<strong>HCH</strong>-2070 Smoking Cessation Patient Teaching Sheet<br />
<strong>HCH</strong>-2230 Snoring/Sleep Apnea Questionnaire Feb-10 E. Wagner<br />
<strong>HCH</strong>-1525 Snoring/Sleep Apnea Questionnaire UMG Replaced by <strong>HCH</strong> 2230 Oct-06 E. Wagner<br />
<strong>HCH</strong>-2168 Social Work Assessment Aug-09 May-10 S. Richmond<br />
<strong>HCH</strong>-2167 Social Work Readmission Assessment Aug-09<br />
<strong>HCH</strong>-2192 Solicitud Voluntaria (Spanish Version Voluntary Application) Oct-09 J. Lounsbury<br />
<strong>HCH</strong>-2387 Soriatane (Acitretin) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-901A Spanish - Permission to Treat Consent Mar-94 Apr-06<br />
<strong>HCH</strong>-2262 Special Infusion Documentation Form Jul-10 Jessie Condon<br />
<strong>HCH</strong>-1864 Special Instructions for Persons Receiving ECT<br />
<strong>HCH</strong>-2266 Special Needs Flowsheet Aug-10 Toni Leers<br />
<strong>HCH</strong>-2139 Special Procedure Note - Concomitant Radiotherapy <strong>and</strong> Chemotherapy (Rad Onc)<br />
<strong>HCH</strong>-2142 Special Procedure Note - HDR Brachytherapy (Rad Onc)<br />
8/3/2012 - 9:53 AM 25/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-2133 Special Procedure Note - Heterotoptic Bone (Rad Onc)<br />
<strong>HCH</strong>-2134 Special Procedure Note - IMRT Therapy (Rad Onc)<br />
<strong>HCH</strong>-2135 Special Procedure Note - LDR Brachytherapy (Rad Onc)<br />
<strong>HCH</strong>-2138 Special Procedure Note - Prostate Seed Implant (Rad Onc)<br />
<strong>HCH</strong>-2141 Special Procedure Note - Stereotactic Radiosurgery (Rad Onc)<br />
<strong>HCH</strong>-37 Special Vital Signs Record Apr-75 Oct.-2008 ICU<br />
<strong>HCH</strong>-896 Speech Pathology Communication Evaluation Jul-94 Jul-06 J. Lounsbury<br />
<strong>HCH</strong>-892 Speech Pathology Interagency Discharge Form Jul-94 Jul-06<br />
<strong>HCH</strong>-1517 Speech Therapy Encounter Note - ENT Oct-06<br />
<strong>HCH</strong>-1631 Speech Therapy Progress Note Nov-06 E.Wagner<br />
<strong>HCH</strong>-1128 Patient <strong>and</strong> Family Teaching Record General Surgery Nov.-97<br />
<strong>HCH</strong>-1656 Spirometry Flowsheet (OCC Med/Emp Hlth) May-94 Nov-06 S.Barnosky/Occ.Med<br />
<strong>HCH</strong>-46 Sports Medicine Referral Dec.-93 Jun-11 B.Boucher-Rehab. Services<br />
<strong>HCH</strong>-770 Sports Rehab <strong>and</strong> Assessment Referral Form<br />
<strong>HCH</strong>-1333 St<strong>and</strong>ard Care Plan1 Dec.-01 Mar-06<br />
SueEllen Goodrich/Karen<br />
<strong>HCH</strong>-2326 St<strong>and</strong>ard Care Plan-Hyperemesis Gravidarum Oct-11<br />
Loscher<br />
<strong>HCH</strong>-2331 St<strong>and</strong>ard Care Plan: Infection Risk or Confirmed Nov-11 SueEllen Goodrich<br />
<strong>HCH</strong>-794 St<strong>and</strong>ard Care Plan Laparotomy: Care <strong>of</strong> the Patient Admitted to OB-GYN Nov-93 Jan-09<br />
<strong>HCH</strong>-952 St<strong>and</strong>ard Care Plan-Third Trimester Bleeding Antepartum Patient Mar-95<br />
<strong>HCH</strong>-1315 St<strong>and</strong>ard Medical Admission Order Sheet Feb.-00 Feb.-06 Medical Staff Office<br />
<strong>HCH</strong>-1940 Statement <strong>of</strong> Electing Voluntary Status (Psych)<br />
<strong>HCH</strong>-2388 Stelara (Ustekinumab) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1632 Subjective Analysis <strong>of</strong> the Singing Voice UMG Nov-06 E.Wagner<br />
<strong>HCH</strong>-2354 Subjective Intake Form May-12 Jennifer Smedberg<br />
<strong>HCH</strong>-2389 Superficial <strong>and</strong> Medium Depth Chemical Peels Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2064 Supplement to St<strong>and</strong>ard Care Plan for Infant with Jun-08 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-2223 Supplement to St<strong>and</strong>ard Care Plan: Infection Risk or Confirmed Jan.-10 Sharon Zaffetti<br />
<strong>HCH</strong>-1251 Patient & Family Teaching Record - Surgical Admission General Teaching Oct.-98 Dec.- 00<br />
<strong>HCH</strong>-2131 Surgical Safety Checklist (OR) Apr-09 Feb-12 C.Schramm<br />
<strong>HCH</strong>-1471 Surgical Scheduling Orders Jun-06 N.Maxwell/OB GYN<br />
<strong>HCH</strong>-1789 Suture Removal (JDH Dermatology) Jan-07 Apr-11 Dermatology/Cathy Sonnenberg<br />
<strong>HCH</strong>-2111 Target100 Patient Data Log<br />
<strong>HCH</strong>-1849 TB Respiratory Isolation Respiratory Training <strong>and</strong> Fit-Test Protocol<br />
<strong>HCH</strong>-1923 Technician Study Log (Sleep Disorders Center)<br />
<strong>HCH</strong>-1913 Technician Study Summary (Sleep Disorders Center)<br />
HCh-2305 TEE Discharge Instructions - Ambulatory Patient Information May-11 Linda Manzelli<br />
<strong>HCH</strong>-1441 Telephone Triage Documentation Record Apr-07<br />
<strong>HCH</strong>-2390 Terbinafine (Lamisil) Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1105 Termination <strong>of</strong> Pregnancy Second Trimester Oct.-97 Oct.-00<br />
<strong>HCH</strong>-1501 Test Result Letter UMG Jan-02 Oct-06<br />
<strong>HCH</strong>-1845 Test Result/Biopsy Result Letter (Division <strong>of</strong> Infectious Disease)<br />
<strong>HCH</strong>-2391 Tetracycline Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-2176 The DOC Consent to Basic Treatment Sep-09<br />
<strong>HCH</strong>-2065 Thyrogen Administration (Cancer Center)<br />
<strong>HCH</strong>-2232 Tinnitus Rating Scale Feb.-10 E. Wagner<br />
<strong>HCH</strong>-2245 Tocilizumab (Actemra) After Care Instructions May-10 C.Kay<br />
<strong>HCH</strong>-2247 Tocilizumab (Actemra) Infusion Record May-10 C.Kay<br />
8/3/2012 - 9:53 AM 26/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-2248 Tocilizumab (Actemra) Pre-Infusion Assessment Checklist May-10 C.Kay<br />
<strong>HCH</strong>-2246 Tocilizumab (Actemra) Pre-Printed Order Set May-10 Jun-10 C.Kay<br />
<strong>HCH</strong>-1277 Total Hip POD 1 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1278 Total Hip POD 2 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-2117 Total Hip POD 0 Progress Note (PT)<br />
<strong>HCH</strong>-1279 Total Hip POD 3 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1280 Total Hip POD 4 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1129 Total Joint Arthroplasty Mar-99<br />
<strong>HCH</strong>-1286 Total Joint Arthroplasty Database (PT) May-99 Feb.-06<br />
<strong>HCH</strong>-1816 Total Joint Protocol Rehab Order (Musculoskeletal Institute - Ortho)<br />
<strong>HCH</strong>-2116 Total Knee POD 0 Progress Note (PT)<br />
<strong>HCH</strong>-1273 Total Knee POD 1 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1274 Total Knee POD 2 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1275 Total Knee POD 3 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1276 Total Knee POD 4 Progress Note Mar-99 Jul-09<br />
<strong>HCH</strong>-1102 Total Laryngectomy Oct.-97 Aug.-02<br />
<strong>HCH</strong>-1665 Toxicological Test Consent <strong>and</strong> Results Release (Occ Med/Emp Hlth)<br />
<strong>HCH</strong>-1132 Tracheostomy Nov.-97 Jan.-01<br />
<strong>HCH</strong>-1091 Tracheostomy (Infant) Sept.-97 Sept.-02<br />
<strong>HCH</strong>-1836 Tranfer <strong>of</strong> Care Letter (Anticoagulation Service)<br />
<strong>HCH</strong>-2087 Transesophageal Echocardiogram (TEE) Report Jan-09 Feb-12 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-2088 Transesophageal Echocardiogram (TEE) Requisition Nov-06 Aug-10 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-1514 Transesophageal Echocardiogram Post Procedure Orders<br />
<strong>HCH</strong>-1513 Transesophageal Echocardiogram Pre Procedure Orders Oct-06 Feb-10 Linda Manzelli/Cardiology<br />
<strong>HCH</strong>-596 Transfer Summary (NICU) Sept.-91 Jul-09<br />
<strong>HCH</strong>-497 Transfusion Reaction Evaluation May-89 Jun-06 Blood Bank<br />
<strong>HCH</strong>-1629 TransNasalEsophogoscopy (TNE) Patient Encounter (UMG) Jan-07 E.Wagner<br />
<strong>HCH</strong>-1535 Travel Orders - Medications / Prophylaxis Orders Oct-06 Jun-10 Ute Schroeder<br />
<strong>HCH</strong>-2148 Treatment Completion Instructions - Nursing (Rad Onc)<br />
<strong>HCH</strong>-1970 Treatment Plan Revision - Nursing (Psychiatry)<br />
<strong>HCH</strong>-1969 Treatment Plan Revision - Occupational Theraist (Psychiatry)<br />
<strong>HCH</strong>-1967 Treatment Plan Revision - Social Worker (Psychiatry)<br />
<strong>HCH</strong>-1968 Treatment Plan Revision - Substance Abuse Counselor (Psychiatry)<br />
<strong>HCH</strong>-1616 Treatment Plan/Behavior Plan Diabetes Education (UMG)<br />
<strong>HCH</strong>-1087 Treatment Plan/Behavior Plan Diabetes Self Management Education Jun-09 n/a Dental/OR C. Schramm<br />
<strong>HCH</strong>-2392 Triamcinolone <strong>and</strong> other Topical Steroids Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-1497 Tuberculosis Questionnaire UMG Aug-06 Ute Schroeder<br />
<strong>HCH</strong>-581 Ultrasound Consultation Request - Order from warehouse (Moore) Dec.05 Jun-06<br />
<strong>HCH</strong>-1467 Ultrasound Patient Information Sheet Jun-06 Jun-12 Ute Schroeder<br />
<strong>HCH</strong>-1987 Ultraviolet B (UVB) Therapy Orders (Dermatology)<br />
<strong>HCH</strong>-2217 Ultraviolet B Narrowb<strong>and</strong> (UVB-NB) Phototherapy Order Sheet Dec.-09 Apr-11 Cathy Sonnenberg<br />
<strong>HCH</strong>-1433 UMG Follow-Up Care Plans Feb.-2006 Sep-07 Osteoporosis Clinic<br />
<strong>HCH</strong>-2150 Universal Protocol Procedural Checklist Jun-09 Aug-11 Carol Schramm<br />
<strong>HCH</strong>-2166 Universal Protocol Procedural Checklist Dental Clinics Jun-09 Dental/C. Schramm<br />
<strong>HCH</strong>-2120 Updated Admission Database (PHP) 00-00 Apr-10 Susan Richmond<br />
<strong>HCH</strong>-1403 NO LONGER A CHART FORM Use <strong>of</strong> Dexamethasone with Infants who Develop Chronic Lung Dise Apr-05 DEACTIVATED 10/2011<br />
<strong>HCH</strong>-1359 Uterine Fibroid Embolization Preprinted Orders Interventional Radiology<br />
<strong>HCH</strong>-1472 Utilization Review Tracking Sheet Partial Intensive Programs Jun-06 K.Susco Nursing Psych<br />
<strong>HCH</strong>-1669 Vaccina Vaccine Consent (UMG Employee Health)<br />
8/3/2012 - 9:53 AM 27/28
Bar Coded <strong>Forms</strong> by <strong>HCH</strong> Number for eHIMS website.xls Sorted by Form Name<br />
<strong>HCH</strong>-1500 Vaccination Consent for FluMist Oct-06 Martha Hein-UMG<br />
<strong>HCH</strong>-1323 Vaccination Notice Form Jan.-01 Feb.-06<br />
<strong>HCH</strong>-1324 Vaccine Record Jan.-01 Sep-11 Newborn Nursery<br />
<strong>HCH</strong>-1031 Vaginal Delivery Care Path Jun-97 Jul-99<br />
<strong>HCH</strong>-873 Post Partum Vaginal Delivery Orders Feb.-94 Jan-10 MFICU<br />
<strong>HCH</strong>-2289 V60 Adult Patient Bipap System Check Record Dec-10 Janet Schoenewolff<br />
<strong>HCH</strong>-1304 Vaginal Delivery Orders After 2nd Trimester Termination Oct.-99 Feb.-06 Sue Goodrich<br />
<strong>HCH</strong>-2393 Valacyclovir - Oral Jul-12 Jane Grant-Kels<br />
<strong>HCH</strong>-580 Vascular Lab Consultation Request - Order from warehouse (Moore) Dec.-05 Jun-06<br />
Jeanette Mazzatto / Linda<br />
<strong>HCH</strong>-2090 Vascular Medicine Testing - Pat <strong>and</strong> Jim Calhoun Cardiology Center Mar-09 Jul-12 Manzelli<br />
Georg'Ann Bona/Cathy<br />
<strong>HCH</strong>-2316 Vbeam Laser Treatment Post Procedure Instructions Aug-11<br />
Sonnenberg<br />
<strong>HCH</strong>-1311 Venous Thrombosis Inpatient Day 1 Order Sheet Aug.-00 May-07<br />
<strong>HCH</strong>-1089 Ventriculoperitoneal (VP) Shunt1 Sept.-97 Dec.-00<br />
<strong>HCH</strong>-1364 Vertebroplasty Kyphoplasty Pre-printed orders Interventional radiology May-03<br />
<strong>HCH</strong>-1100 Violent Restraint/Self-Destructive Restraint/Seclusion Order Sheet Oct.-97 May-12 Nursing / Am<strong>and</strong>a Darcey<br />
<strong>HCH</strong>-1519 Voice H<strong>and</strong>icap Index Questionnaire - ENT 00-05 Feb-09 Otolaryngology<br />
<strong>HCH</strong>-2202 Volume Control Flowsheet A Nov.-09 Nov-10 J. Schoenewolff<br />
<strong>HCH</strong>-967 Voluntary Application Sept.-95 Mar-07<br />
<strong>HCH</strong>-2324 Voluntary Application for Admission Oct-11 Judith Lounsbury<br />
<strong>HCH</strong>-2348 Volunteer Immunization Documentation Form Mar-12 Janet Pinto<br />
<strong>HCH</strong>-1316 W-10 - Order from warehouse (Moore) Hospital Nursing<br />
<strong>HCH</strong>-1814 Warning/Termination Letter (UMG)<br />
<strong>HCH</strong>-1807 Wavefront Laser Vision Correction Consent (UMG)<br />
<strong>HCH</strong>-2206 Web Consent Form Nov.-09 Sheryl Rosen<br />
<strong>HCH</strong>-1828 Weight Chart (UMG/JDH)<br />
<strong>HCH</strong>-2164 Welcome to the Inpatient Behavioral Health Unit - Psychiatry 1<br />
<strong>HCH</strong>-2188 Welcome to the Inpatient Behavioral Health Unit - Psychiatry 3 Oct.-09 J. Lounsbury<br />
<strong>HCH</strong>-2193 Well Newborn Flowsheet Nov.-09 T. Donovan<br />
<strong>HCH</strong>-959 Wheelchair Assessment (Outpatient Rehab) 00-00 Aug.07 Rehab Services<br />
<strong>HCH</strong>-1524 Work Release / Job Restrictions - Orthopaedic Surgery 00-05 Jul-11 K. Clarke- Orthopaedic Surgery<br />
<strong>HCH</strong>-2122 Written Patient Disclosure: Orthopaedic Inventions <strong>and</strong> Know How<br />
<strong>HCH</strong>-2069 Zoledronic Acid (Reclast) After Care Instructions<br />
<strong>HCH</strong>-2034 Zoledronic Acid (Reclast) Aftercare Instructions (Rheum Infusion)<br />
<strong>HCH</strong>-2033 Zoledronic Acid (Reclast) Infusion Record (Rheum Infusion)<br />
<strong>HCH</strong>-2037 Zoledronic Acid (Reclast) Pre-Infusion Assessment Checklist (Rheum Infusion) Oct-99 Sep-09 Labor & Delivery<br />
<strong>HCH</strong>-2068 Zoledronic Acid (Zometa) Infusion Orders Sep-09<br />
<strong>HCH</strong>-2073 Zoledronic Acid (Zometa) Infusion Record Sep-09<br />
<strong>HCH</strong>-2067 Zoledronic Acid (Zometa) Pre-Infusion Assessment Checklist Sep-09<br />
<strong>HCH</strong>-1756 Zoledronic Acid Infusion Order Set Dec-06 Dec-10 Jessie Riemer<br />
8/3/2012 - 9:53 AM 28/28
Change language