For Our Physicians Preprinted Orders & Hospital Forms Preprinted Orders Core Measures Hospital Forms Patient References/Tools Translated Forms Unit Specific Orders & Forms Hospital Forms Preprinted Orders and Hospital Forms Number Title Category Ventilator Protocol Worksheets SMCS Preoperative Work Sheet Worksheets 5 East CVIU Orientation Packet Worksheets SMH - ICU - CICU Agency Orientation Packet Worksheets SGH - ICU Agency Orientation Packet ý Worksheets SMH ED Orientation Packet Worksheets SGH ED Orientation Packet Worksheets 4 W Oncology Orientation Packet Worksheets 5 South Float - Agency Orientation Packet 2008 Worksheets 4 South Float - Agency Orientation 2008 Worksheets 4 North Orthopedics Orientation Packet Worksheets 4 East Neurology Orientation Worksheets 3C SBAR Report Form Worksheets Ticket for Two Worksheet Worksheets SMH PAA Assignment Sheet Worksheets SGH PAA Assignment Sheet Worksheets 3C Float Packet Worksheets Patient's Guide to Blood Transfusion Worksheets PAA Report Sheet Worksheets PAA Activity Log Worksheets Patient Activity Aide- Unit Evaluation Form Worksheets Per Diem LVN- Unit Evaluation Form Worksheets Per Diem Monitor Tech - Unit Evaluation Form Worksheets Per Diem Nursing Assistant - Unit Evaluation Form Worksheets Per Diem Registered Nurse - Unit Evaluation Form Worksheets Per Diem Unit Secretary - Unit Evaluation Form Worksheets Smoking Cessation Patient Information Patient Education Confidential Morbidity Report Legal SGH IV Therapy Worksheet Worksheets SMH IV Therapy Worksheet Worksheets 00034 EKG Rhythm Strips Nursing Documentation 00035 Pediatric discharge Instructions for Cardiac Catherization Print 2 Copies Discharge Instructions 00043 SCN Protocol Log Nursing Documentation 00067 Autopsy: Authorization for.. Print 2 Copies Consents 00075 Fetal /Neonatal Plan of Care MD Documentation, Nursing Documentation 00082 D&C / Hysteroscopy Post Op DC Instructions Discharge instructions Print 2 Copies Discharge Instructions 00083 Post-Op Laparoscopy Surgery Discharge Instructions Print 2 Copies Discharge Instructions 00088 Admission Physical Assessment Nursing Documentation 00148 Standard Care Statement Outpatient Surgery Nursing Documentation 00152 Death: Record of Death & Disposition Form in Central Services 00215 Continuing Education Duty Time Request Hospital 00228 ACU Post Op Phone Call Nursing Documentation 00235 Paul Gann Transfusion Information Form Print 2 Copies Consents 00285 Physician Progress Notes MD Documentation 00310 SCN Patient Profile Nursing Documentation, SCN 00338 Discharge Instructions - Generic Nursing Print 2 Copies Discharge Instructions 00351 Pediatric Outpatient Record Nursing Documentation 00365 Sponge, Instrument and Needle Counts - Surgery Nursing Documentation 00395 Consent for Vaccine Administration Print 2 Copies Consents 00431 Refusal of Treatment, Procedure and/or Safety Device Hospital 00511 Patient Profile Inpatient Adult Nursing Documentation 00512 Pre-Ops Teaching Confirmation Nursing Documentation 00529 Communicable Disease Exposure for ED Personnel Nursing Documentation 00576 MAR - Medication Administration Record MAR's 00604 Nursery 'Special Tests Record' Worksheets 00650 Anesthesia Evaluation MD Documentation 00659 Cardiac Cath Lab Pre-Procedure Check-list Nursing Documentation 00660 Exercise Testing patient Information, CV non-invasive Lab Print 2 Copies Consents 00669 MAR - Medication Administration Record for Short Term Areas MAR's 00719 Pediatric Procedure Pre-Anesthesia Checklist Nursing Documentation 00736 Authorization for Restriction on Release of Personal Health Information (No info) Hospital 00749 Discharge Instructions for Post Heart Catheterization/Angioplasty/Stent Care Print 2 Copies Discharge Instructions 00787 Diabetic Record Nursing Documentation 00832 Photo Consent- Adult; Consent to Photograph, Filming, Videotaping, or use of Recording Devices Print 2 Copies Consents 00842 Nursing Pharmacy Requisition Worksheets 00902 Parenteral Fluid Administration Record Nursing Documentation 00966 Consultation Record MD Documentation 01024 Patient Orientation SOMT 01052 Lost/Damaged Property Hospital 01070 Surgical Checklist Nursing Documentation 01186 L&D MD Physical Exam MD Documentation 01206 IABP- Intra-Aortic Balloon Pump Flowsheet Nursing Documentation 01246 PICC Record Nursing Documentation, Hard Copy Only 01367 - Gen AdultAdult Outpt. Home Care Inst. PACU, ACU Print 2 Copies Discharge Instructions 01367 - Mem Adult OP Home Care Instructions Print 2 Copies Discharge Instructions 01376 Labor & Delivery Pre-Op Surgical Checklist Nursing Documentation 01448 IV Therapy Documentation Record Nursing Documentation, Hard Copy Only 01630 ACU Post Op Patient Progress Report Nursing Documentation 01649 L&D OB Check Print 2 Copies Discharge Instructions 01689 Lithotripsy Patient Treatment Record MD Documentation 01692 Autotransfusion Record Nursing Documentation 01705 Cath Lab Post Procedure HCHA Progress Record Nursing Documentation Nursing Documentation 01706 Outpatient Discharge Instructions Print 2 Copies Discharge Instructions 02239 Consent for Transport to SMH Print 2 Copies Consents 02266 Neurological Flowsheet Nursing Documentation 02424 Ambulatory Care Unit Pre- Op Flow Sheet Nursing Documentation 02452 Advanced Life Support Notes SCN 02452 Advanced Life Support Notes (Continuation) SCN 02657 Apheresis Unit - Hematopoietic Progenitor Cells Apheresis (HPC, Apheresis) Report of Adverse Reaction Event Nursing Documentation 02762 Seizure Log Nursing Documentation 02910 L&D Sponge, Needle and Inst. Count Nursing Documentation 02933 Fetal Movement Diary Category Worksheet Worksheets 06157 Medication Event & Near Miss Evaluation Hospital 09125 SCN Diode Laser Procedure Record Nursing Documentation 09268 Sedation Record, Patient Nursing Documentation 09269 Outpatient Instructions After Sedation Print 2 Copies Discharge Instructions 09353 Social Work Consultation Psycholsocial Assessment Social Work 09422 Patient Profile, Pediatrics Nursing Documentation 09455 Outpatient Discharge Instructions Biopsies, Pacemakers, ICD's Print 2 Copies Discharge Instructions 09513 Fire Event Evaluation Hospital 09545 Short Form Operative and Invasive Procedures MD Documentation 09755 Employment and Orientation Notification Worksheet Worksheets 09977 Standard Care Statement for Patients Having Surgery Nursing Documentation 20022 PCA Intravenous Patient-Controlled Analgesia Patient Education 20129 Photo Consent, Pediatric Print 2 Copies Consents 20141 Elimination Program Daily Record SOMT 20142 Informed Refusal L&D and ED Print 2 Copies Consents 20143 3C Assignment Sheet and Break Log Worksheets 20207 Physician Pre-Procedural Assessment /cath lab-EP Lab MD Documentation 20252 Fall Management Conference SOMT 20262 Deep Brain Stimulation Phase 1 Print 2 Copies Discharge Instructions 20274 Deep Brain Stimulation Phase 2 Print 2 Copies Discharge Instructions 20283 Resuscitation Review Nursing Documentation 20301 Crash Cart Checklist Nursing Documentation 20385 PICC and Midline Maintenance Guide Nursing Documentation 20392 Managing Your Pain: what you need to know Patient Education 20419 Dept. Charges IV Therapy Worksheets 20433 Staffing Office Info to Fax Worksheet Worksheets 20622 Obstetric Ultrasound Exam Report MD Documentation 20650 Authorization for Use or Disclosure of Health Information Print 2 Copies Consents 20675 MD Progress Notes (formatted) MD Documentation 20699 ACU Admitting Nurse Notes Nursing Documentation 20723 Pregnancy Activity Levels Antepartum Patient Guidelines Patient Education 20725 Cervical Discectomy Flowsheet Nursing Documentation 20734 Canine Companion Facility Dog Consent Print 2 Copies Consents 20756 Car Seat Resources Patient Education 20777 EMU Monitor Tech Activity Sheet Worksheets 20797 5C Assignment Sheet and Break Log Worksheets 20798 PICC Alert Sign Nursing Documentation 21000 2C Assignment Sheet and Break Log Worksheets 21010 Heart Care At a Glance, Heart Failure Discharge Instructions Print 2 Copies Discharge Instructions 21015 Colonoscopy Discharge Instructions Print 2 Copies Discharge Instructions 21022 3C / 5C Inter-Staff Communication/ I & O's Worksheets 21027 Orthostatic Blood pressure Nursing Documentation 21069 Endoscopy Pre Procedure H&P MD Documentation 21090 Surgical Services Site/Side Documentation Nursing Documentation 21097 Addendum to Standard Care Statement Nursing Documentation 21146 Neonatal Abstinence Flow Sheet Nursing Documentation 21178 Patient Identification - Diagnostic Imaging Radiology / IR Hospital 21184 Glucophage, Patients taking Print 2 Copies Discharge Instructions 21217 OrthoPAT Record Nursing Documentation 21224 Dysphagia Screening for Stroke Patients Nursing Documentation 21226 Thoracic or Lumbar Laminectomy/Disectomy Flowsheet Nursing Documentation 21227 Renal Dialysis 24-Hour Peritoneal Flowsheet Nursing Documentation 21244 Perinatal Flowsheet Nursing Documentation 21288 Consent Capsule Endoscopy Print 2 Copies Consents 21293 Pediatric Op Home Care Instructions Print 2 Copies Discharge Instructions 21306 Post Procedural Call Cardiac Cath / EP Lab Nursing Documentation 21308 Consent PICU/ED eHealth Consultation Print 2 Copies Consents 21311 Central Venous Cath Homecare Print 2 Copies Discharge Instructions 21328 Ostomy Care Documentation WOCN 21341 Stroke RN Acute Progress Note Nursing Documentation 21356 ED and L&D Transfer / Consent Print 2 Copies Consents 21360 GI Endoscopy Post Procedure Call Nursing Documentation 21364 Patient Refusal to Transfer Print 2 Copies Consents 21366 Sirolimus Flow Worksheet Worksheets 21367 Tacrolimus Flow Sheet Worksheets 21368 Cyclosporine Flow Worksheet Worksheets 21370 Dev. Delayed Addendum Stnd Care Statement Nursing Documentation 21371 SCS for Patients Having Out of Dept Procedure with Anesthesia/Sedation Nursing Documentation 21390 Pneumococcal/Influenza Immunization Protocol Nursing Documentation 21393 Pediatric Intensivists Progress Note MD Documentation 21411 Asthmas Treatment Inst. Peds Home Care Print 2 Copies Discharge Instructions 21414 Pyxis User Request Hospital 21415 2C Interstaff Communication Worksheet Worksheets 21422 Consent Cardiac Cath Coronary Intervention - Use for non-Sacramento Heart and Vascular Cardiologists Print 2 Copies Consents 21423 Consent Cardiac Cath Coronary /Peripheral Intervention - Use for Sacramento Heart and Vascular Cardiologists Print 2 Copies Consents 21424 Pacemaker Homecare Inst. Sacramento - Heart and Vascular Med Association Print 2 Copies Discharge Instructions 21425 Pacemaker/ ICD Homecare Inst. Sobkowicz/Berte Print 2 Copies Discharge Instructions 21426 Core Measures Tool Worksheets 21427 Pacemaker / ICD Homecare Inst. Wolf Print 2 Copies Discharge Instructions 21428 Mental Health Evaluation Tool MSW Documentation 21429 ATU Photograph Consent Print 2 Copies Consents 21431 Monitor Tech Patient Report Worksheets 21434 ED Lab Results Letter Worksheets 21439 Temporary Absense/Transfer Release Print 2 Copies Consents 21454 Pacemaker/ICD Homecare Instructions- Dr Kim Print 2 Copies Discharge Instructions 21478 HRM Report: Antepartum Worksheets 21479 HRM Report: Postpartum Worksheets 21510 Pressure Ulcer Program Patient Information Patient Education 21525 Pediatric Asthma PCP Notification, ED MD Documentation 21527 Tobacco Cessation Follow-Up Print 2 Copies Consents 21531 SMCS Admission Orders - Dr Morkoc Nursing Documentation 21536 Dialysis Outpatient Initial Patient Education Nursing Documentation 21539 Transport Flowsheet (SCN) Nursing Documentation 21583 Outpatient Medication Reconciliation Form Nursing Documentation 21592 OB Recovery Nursing Record Continuation Nursing Documentation 21593 VAD Heartmate XVE Flowsheet Nursing Documentation 21602 Social Work Progress Note Social Work 21609 VAD Abiomed Flowsheet Nursing Documentation 21618 Ticket to Ride Worksheet Worksheets 21624 Diagnostic Test MRI Diagnostic Imaging Documentation 21633 SMCS - Surgery Letter Patient Education 21634 ICD Discharge Instructions - Dr. Stark Print 2 Copies Discharge Instructions 21640 Discharge Instructions for Care at Home - Adults Print 2 Copies Discharge Instructions 21642 Pacemaker / ICD Homecare Inst.- Generic Print 2 Copies Discharge Instructions 21655 VAD CentriMag Flowsheet Nursing Documentation 21672 MAR - Insulin Regular - Mild MAR's 21673 MAR - Insulin Regular - Moderate MAR's 21674 MAR - Insulin Regular - Aggressive MAR's 21675 MAR - Insulin Lispro - Mild MAR's 21676 MAR - Insulin Lispro - Moderate MAR's 21677 MAR - Insulin Lispro - Aggressive MAR's 21681 Physician Predischarge Assessment of Risk for Hyperbilirubinemia in Infant 35 Weeks Gestation (or greater) MD Documentation 21693 ROP Follow-up MD Documentation 21696 Daily Progress for CV Surgery Patient Education 21710 Blood and Marrow Transplantation Program Summary of Records Worksheets 21711 Blood and Marrow Transplantation Program Final Donor Suitability/Eligibility Determination Worksheets 21719 Teaching Checklist - Stroke Patient Education 21723 MAR - Bowel Care - Renal MAR's 21724 MAR - Bowel Care - Routine MAR's 21725 MAR - Potassium and Magnesium Replacement Protocol MAR's 21726 MAR - Heart Failure Admission Orders 09912 MAR's 21727 MAR - Pneumonia Order Set, Adult ZZ00167 MAR's 21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's 21729 MAR - Chest Pain - Rule out Acute Coronary Syndrome 20663 MAR's 21739 Advanced Directives Intensity of Care SOMT 21740 Bladder Retraining Assessment SOMT 21741 Monthly Meal Intake Record SOMT 21742 Pressure Ulcer Clinical Summary SOMT 21743 Psychotropic Medication Summary Sheet SOMT 21744 Sepsis Screen SOMT 21745 Quarterly Smokers Assessment SOMT 21748 Ventricular Assist Device Flowsheet for Heartmate II Nursing Documentation 691127 Restraint Directive SOMT

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