University of Management and Technology Forms Repository Worksheet

University of Management and Technology Forms Repository Worksheet University of Management and Technology Forms Repository Worksheet In the attached excel spreadsheet, I am having some issues with the following: Under Form ID column E, the drop-down menu does not display all the department identifiers from the pick-list. Under Version Control column Q, the drop-down menu does not display all the proper version controls from the pick-list. When I try to filter out all patient facing forms, it is not filtering out the blanks. forms_repository.xlsx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Form Name New Form Name Form # New Form # Delivery Record Benefis Ambulatory Pharmacy White Original/Pharmacy copy, Yellow Delivery Copy/Obtain Patient Signature then return to Pharmacy, Pink Patient copy 005-5001 FAC 0001 FAC-0001 Delivery Record Benefis Ambulatory Pharmacy White Original/Pharmacy copy, Yellow Delivery Copy/Obtain Patient Signature then return to Pharmacy, Pink Patient copy Validation Notes 005-5001 FAC 0001 FAC-0001 Physician Order / Laboratory Test Requisition White, Yellow, Pink with no instructions. Physician Order / Lab Requisition 005-5002 CLI 2/19 ORD 005-5002 FAC 4/12 ORD Physician Order / Laboratory Test Requisition no carbon copy instructions. Downtime form. Usually print a different version from EMR Emergency Department Discharge Instructions Emergency Department Discharge Instructions Physicians Orders Scanned after discharge or deceased Senior Care Center Medication Regimen Review Stat / Now / One-Time Medication Administration Record in EHR no reason to keep form Registration Operative Nursing Assessment Doctor Appointment Card Treatment Consent Form – Pediatrics Patients Authorization for Treatment Pediatric Patients Treatment Consent Form – Pediatrics Patients Authorization for Treatment Pediatric Patients Authorization to Release Birth Announcement Information to the News Media Remove ‘Legal Health Record’ mention replace with ‘Electronic Health Record’ Mnemonic Logo(text) _ Hospitals Barcode Scanned? NextGen Document Type _ Hospitals X Hospitals Order (New) MR Reports (SCANNED) MR Reports (SCANNED) FAC 0024 FAC-0024 ERINST X Hospitals x MT FAC 0024 FAC-0024 ERINST X Hospitals x MT 005-5011 FAC 10/07 ORD Hospitals x MT 005-5012 SEN 12/16 SNMED Hospitals x MT Patient Care Documentation MT Patient Care Documentation 8/09 005-5013 10/08 005-5016 x FAC 1/10 MAR _ PREOP Health System x Hospitals x Surg/Proc Documentation MT CLI 005-5028 CLI 005-5032 FAC 0001 0001 CLI-0001 10/18 CLI-0001 CONSENT X CONSENT X 11/00 _ Hospitals x FAC 0025 FAC-0025 Hospitals x Hospitals x 7/13 I MedRec Women’s and Children’s Services MT Misc Consent/Release Clean-up Women’s and Children’s Services RELEASE X Hospitals x Misc Consent/Release MT TICKET Hospitals X Administrative Data 005-5050 FAC 6/11 TICKET Hospitals X Administrative Data FAC-0025 FAC CLI 005-5073 005-5085 FAC 005-5088 FAC 0026 FAC-0026 005-5088 FAC 0026 FAC-0026 005-5104 FAC RELEASE X x _ x _ 2/16 _ 5/05 CTHX 4/12 CONSENT X CONSENT X 7/86 8/13 FAC UNI 0005 UNI-0005 005-5133 UNI 0005 UNI-0005 FAC 0011 FAC-0011 Hospitals x RELEASE RELEASE 11/17 RELEASE X 7/12 x 005-5165 FAC 2/16 005-5172 FAC 1/00 card stock. specific to Dr Schaefer 005-5173 FAC 2/10 VanGilder ACDF & Lumbar Kardex card stock. specific to Dr VanGilder 005-5174 FAC 005-5180 005-5210 FAC 005-5228 FAC last ordered 8/22/19 last ordered 1/10/20. Created by marketing last ordered 1/28/20 last ordered 4/4/19. no instructions for carbon copy Critical Care Flowchart 2/10 005-5228 FAC 0017 FAC-0017 005-5228 FAC 0017 FAC-0017 005-5241 X Health System x Health System x MT Radiology Reports Consent/Authorizat ions Consent/Authorizat ions Expiration Documentation Expiration Documentation MT 005-5325 005-5329 005-5521 Dismissal Instructions penny checking last ordered 11/20/17. White, Yellow, Pink (No instructions) last ordered 1/21/20. Revision sent to Medrec by Reanna Brown Card Stock Card Stock Care Agreement FAC FAC PHREF x _ x 9/95 _ _ 10/19 IMPMSGDSCH 3/20 Hospitals _ UNI UNI UNI 0001 UNI-0001 UNI 0001 UNI-0001 3 per page perforated (same info as 0055980) Expiration Protocol Send to Ray with 3330652 Send to Ray with 3330652 2 per page perforated (same info as 0055931) 2 per page perforated (same info as 0055931) x PV x Y x x x x x Carbon Copy Allegra Final A Radiology x Radiology Paul Fulbright Greg Hilpert Clean-up Radiology x Radiology Paul Fulbright Greg Hilpert Clean-up x x PV Clinic Women’s and Children’s Services Allegra Final Scott Schandelson Kevin Langkiet Medical Records Joan Rand Nelson Liston x Carbon Copy Women’s and Children’s Services Kristen Srna Caroline McConville x Carbon Copy Administrative Data Patient Care Documentation Patient Care Flow Sheets Dismissal Instructions/Notes Nikki Walsh Lynze Cannon x Women’s and Children’s Services Kristen Srna Caroline McConville x x Acute Care A I x x PV x Rehab – Inpatient Other Care Coordination/CDI Care Coordination/CDI Care Coordination/CDI x x x x x x Card Stock A x Hospital Wide A x . University of Management and Technology Forms Repository Worksheet Emergency Dept Scott Schandelson Kevin Langkiet x A x Critical Care Tara Eckenstein Kevin Langkiet x x CMS Carbon Copy (2-part) CMS Carbon Copy (2-part) x x x Jill Newbrough x x Carbon Copy (2-part) Linda Tschetter Jill Newbrough x x Carbon Copy (2-part) Kristen Srna Darci Bernardi Caroline McConville Jamie Leonard x INST Healthcare x MT 1/18 ORD Health System x MT Patient Care Documentation MR Reports (SCANNED) 10/18 ORD Health System x MT 2/20 ORD Health System x MT ANES ANES 8/15 10/18 CAREAGREE x MT X Health System x Hospitals I MR Reports (SCANNED) Physician Orders PV MedRec MR Reports (SCANNED) Physician Orders A MedRec CONSENT2 Hospitals x CONSENT2 Hospitals x Hospitals x x Jamie Leonard x x Liz Coates x Liz Coates x Surgical Services Brandi Cornwell x Surgical Services Brandi Cornwell Care Agreement Clean-up Hospice & Ambulatory x Care Agreement Surgical/Procedur e Surgical/Procedur e Surgical/Procedur e Clean-up Hospice & Ambulatory x Enterprise Wide Care Coordination/CDI Care Coordination/CDI PV Radiology PV MT Surg/Proc Documentation Surg/Proc Documentation Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions MT Consent/Authorizat ions Surgical/Procedur e MT Consent/Authorizat ions Surgical/Procedur e Frequent Monitoring Record ECG RHYTYM _ Hospitals Hospitals x x MT Diagnostic Testing LATEX Hospitals x MT MT REFUSAL X HealthCare x MT HealthCare x MT CONSENTMISC X Hospitals x MT Hospitals x MT X 6/12 _ Hospitals Anesthesia Record Anesthesia Record Care Agreement ECG Rhythm Strips Patient Care Documentation Latex Allergy Assessment MR Reports (SCANNED) Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Patient Progress Notes Misc Consent/Release Misc Consent/Release Misc Consent/Release Misc Consent/Release Misc Consent/Release none none none none PV A PV Women’s and Children’s Services x x x Radiology & Lab Women’s and Children’s Services Enterprise Wide x x PV x Enterprise Wide x x Y x Women’s and Children’s Services x Enterprise Wide x x Y x Revision Women’s and Children’s Services x Enterprise Wide x x Y x x Hospital Wide Y x I A I I MedRec (scan) Allegra Final x x Women’s and Children’s Services Emergency Dept Hospital Wide Women’s and Children’s Services x Hospital Wide A Senior Services x Hospital Wide Lab Women’s and Children’s Services x Laboratory Scott Schandelson Kevin Langkiet Kristen Srna Caroline McConville Wade Nelson Greg Hilpert x x Allegra Final x x x x x Hospital Wide Clean-up Clean-up x x x Senior Services x Clean-up I Clean-up Clean-up I I x x x x x A x Debbie Vance x Debbie Vance x Deborah Benner Deborah Benner Patty Harris Patty Harris Pharmacy Darci Bernardi Jamie Leonard x Allegra Final Acute Care Nikki Walsh Lynze Cannon x Allegra Final Allegra Final Allegra Final 005-5931 333-0652 FAC UNI 10/18 0008 UNI-0008 X Expiration Documentation Expiration Documentation EXPIR Hospitals x MT 3/16 EXPIR Hospitals x MT 5/18 AMA X Hospitals x AMA X Hospitals x 4/14 AMA X Hospitals x MT Administrative Data AMA X _ Hospitals x MT X Administrative Data x Administrative Data 333-0652 UNI 0008 UNI-0008 333-1254 FAC 0111 FAC-0111 Administrative Data 333-1254 005-5979 FAC FAC 0111 FAC-0111 005-5980 FAC 7/18 _ X 005-5980 FAC 12/11 _ X Expiration Protocol Expiration Protocol Leaving Hospital AMA Leaving Hospital AMA Leaving Hospital AMA Leaving Hospital AMA x Y x Y x Allegra Final A x PV x x Enterprise Wide x x x Enterprise Wide Behavioral Health Services – IP Behavioral Health Services – IP Hospital Wide A x Acute Care Nikki Walsh Lynze Cannon x Y x PV x Acute Care Lynze Cannon x Y x Kevin Langkiet x Clean-up Clean-up x Clean-up A Hospital Wide Y Clean-up x Hospital Wide Allegra Final x x Raymond Penyak x x Raymond Penyak Angela Trainor Raymond Penyak Angela Trainor x x x x x x x x x x Allegra Final Allegra Final Card Stock White Allegra Final Allegra Final 7/16 x Hospitals x MT CONSENT X ERCHEST Benefis x NG CONSENT X Benefis x NG Consent/Authoriz ations Consent/Authoriz ations Surgical/Procedur e Surgical/Procedur e . University of Management and Technology Forms Repository Worksheet Emergency Dept Documentation Demographics/Ad min/Legal Demographics/Ad min/Legal ER Chest Pain Flow Sheet A x Emergency Dept Nikki Walsh Scott Schandelson Consents Clean-up x Pediatrics – Clinic Michael Zeren Amy Linder x x Consents Clean-up x Pediatrics – Clinic Michael Zeren Amy Linder x x x Pediatrics – Clinic Michael Zeren Amy Linder x x Rheumatology Clinic Chad Bralick Amy Linder x x A Clinic x Family Medicine Clinic Megan Gimenes Amy Linder x x I Clinic x Pediatrics – Clinic Michael Zeren Amy Linder x 005-6035 CLI x _ Benefis X A x Family Medicine Clinic Megan Gimenes Amy Linder x 005-6040 CLI x _ Benefis X A x Outpatient – All Amy Linder x Clean-up x Emergency Dept Clean-up I I x x x Emergency Dept Hospital Wide Hospital Wide PV x Spectrum 333-1382 8/16 AMA X x x AMA X _ _ Hospitals x MT Administrative Data Leaving Hospital AMA Hospitals x MT Administrative Data Leaving Hospital AMA Clinic x Women’s and Children’s Services & Ambulatory Kevin Langkiet Scott Schandelson Kevin Langkiet 0061 FAC-0061 FAC 0061 FAC-0061 333-0117 SPEC 10/18 SPEC 6/17 Spectrum Medical PV x Spectrum Brad Garpestad SPEC x Spectrum Medical PV x Spectrum Brad Garpestad x Spectrum Medical BT TC Exercise Clean-up x Spectrum Brad Garpestad x Spectrum Medical BT TC Exercise Clean-up x Spectrum Brad Garpestad I x Spectrum Brad Garpestad I x Spectrum Brad Garpestad Spectrum Brad Garpestad Exercise Recommendations last ordered 4/11/17 333-0119 SPEC 0017 SPEC-0017 Exercise Recommendations Home Health Agency Outcome and Assessment Information Set (OASIS) 333-0119 SPEC 0017 SPEC-0017 Home Health Packet 333-0120 SPEC x Home Health Agency Outcome and Assessment Information Set (OASIS) No Medicate/Medicaid Coverage Home Health Packet 333-0121 SPEC x 333-0122 SPEC Spectrum Medical x 333-0123 SPEC 0020 SPEC-0020 333-0123 SPEC 0020 SPEC-0020 Spectrum Medical x _ UNI 6/11 _ 333-0126 FAC x _ last ordered 2/14/14 in EHR. Use for brand new pt reg in EHR. Use for brand new pt reg 333-0127 FAC x _ 333-0128 SPEC 0018 SPEC-0018 333-0128 SPEC 0018 SPEC-0018 DME Packet 333-0129 SPEC DME Packet 333-0130 SPEC Patient Business Services New Patient Information DME Packet 333-0130 SPEC Patient Business Services New Patient Information DME Packet 333-0130 SPEC Clean your Hands DME Packet 333-0131 PV Spectrum Medical x 333-0124 last ordered 2/14/14 x x Clean-up Spectrum Medical x Spectrum (Home Health) Donna Rollinson Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell x Jamie Leonard Teresa O’Connell x Greg Hilpert x Kevin Langkiet x Greg Hilpert x x x Heart & Vascular Cathy Burnstein x Spectrum Brad Garpestad Spectrum Medical X Clean-up x Spectrum Brad Garpestad PV X PV x Spectrum (Home Health) Spectrum Ben Buckridge Spectrum Ben Buckridge 0001 SPEC-0001 5/19 Spectrum Medical X x Spectrum Ben Buckridge 0001 SPEC-0001 11/20 Spectrum Medical X A x Spectrum Ben Buckridge SPEC 0019 SPEC-0019 x Spectrum Medical X Clean-up Spectrum (Home Health) x Spectrum Ben Buckridge DME Packet 333-0131 SPEC 0019 SPEC-0019 Spectrum Medical X Clean-up Spectrum (Home Health) x DME Packet 333-0132 SPEC 3/19 Spectrum Medical X PV Spectrum (Home Health) DME Packet 333-0132 SPEC 1/12 Spectrum Medical X PV Spectrum (Home Health) DME Packet 333-0132 SPEC 0002 SPEC-0002 4/19 DME Packet 333-0132 SPEC 0002 SPEC-0002 11/20 last ordered 8/13/18. no carbon copy instructions. Send white copy to assisted living. Use paper chart 333-0134 CLI Patient Information – Registration form 333-0135 SPEC x Referring Diagnosis Card 333-0137 FAC x last ordered 2/14/17 333-0140 last ordered 12/4/19 333-0141 333-0143 x FAC x _ Ben Buckridge Ben Buckridge x Spectrum Ben Buckridge Spectrum Ben Buckridge x Benefis Ambulatory Pharmacy (BAP) Rose Kommers Spectrum Medical X PV Spectrum (Home Health) X A Spectrum (Home Health) Hospitals X A I x Spectrum Brad Garpestad X I x Laboratory x Emergency Dept Wade Nelson Scott Schandelson Spectrum Medical _ _ x X x MT Surg/Proc Documentation Bronch Preliminary Rpt x MT Emergency Dept Documentation ER Mercy MedFlight FAC x x 333-0144 FAC 1/10 Advance Beneficiary Notice of Noncoverage (ABN) 333-0145 SPEC x 333-0153 333-0157 FAC FAC 9/05 x ERFLIGHT _ _ _ Healthcare Pre-Bypass Checklist 333-0163 FAC 5/01 _ Healthcare x Perfusion Record Discharge Instructions for Fiberoptic Bronchoscopy Discharge Instructions for Fiberoptic Bronchoscopy Autotransfusion Flowsheet 333-0164 333-0169 333-0169 333-0182 FAC 5/06 4/12 1/01 7/01. University of Management and Technology Forms Repository Worksheet PERFUSION _ _ _ Healthcare Healthcare Healthcare Healthcare x x x x MT Cardiopulmonary Arrest Record Shipping Request 333-0213 333-0218 3/18 3/09 ARREST Hospitals Health System x MT X INST Health System x MT BRONCH Spectrum Spectrum Spectrum Medical Mercy Flight Perinatal Transport Rx for Lisa Guzman, FNR, BC, DNP FAC PV A X X Hospitals A I Spectrum Medical 333-0236 FAC 4/12 DME Packet. Walker 333-0245 SPEC 12/18 Spectrum Medical DME Packet 333-0245 SPEC 6/17 Spectrum Medical Clinic Extracorporeal Perfusion Patient Care Documentation Cardiopulmonary Arrest Record Patient Care Documentation Dismissal Instructions/Notes X I I Ben Buckridge x x x Heart & Vascular Cathy Burnstein Donna Rollinson x I I I I x x x x Surgical Services Brandi Cornwell Liz Coates x A ? x Hospital Wide Other x Radiology Paul Fulbright Spectrum Ben Buckridge Ben Buckridge Allegra Surgical Services Brandi Cornwell PV Spectrum (Home Health) Women’s and Children’s Services & Spectrum (Home Health) x Spectrum Spectrum (Home Health) Women’s and Children’s Services Spectrum Ben Buckridge x Spectrum Ben Buckridge Spectrum Ben Buckridge Spectrum Ben Buckridge Spectrum Ben Buckridge 333-0246 SPEC 0003 SPEC-0003 1/19 Spectrum Medical BT DME Packet 333-0246 SPEC 0003 SPEC-0003 11/20 Spectrum Medical BT A DME Packet. carbon copy remove page reference 333-0247 SPEC 12/18 Spectrum Medical BT Prog I Spectrum (Home Health) Spectrum Ben Buckridge BT PV Spectrum (Home Health) Spectrum Ben Buckridge BT PV Spectrum (Home Health) A Spectrum (Home Health) SPEC x Spectrum Medical SPEC 0004 SPEC-0004 4/19 Spectrum Medical DME Packet 333-0248 SPEC 0004 SPEC-0004 10/20 333-0249 CLI 333-0250 FAC 0073 FAC-0073 333-0250 FAC 0073 FAC-0073 333-0303 CLI 333-0303 CLI For your baby (gift) 333-0317 FAC 0074 FAC-0074 For your baby (gift) 333-0317 FAC 0074 FAC-0074 333-0340 CLI PV Spectrum Medical BT _ Benefis NG x _ Health System X _ Health System X Medical Correspondence Patient Questionnaire POSTOP Hospitals x MT Surg/Proc Documentation Pre/Peri/Postop Nurs Doc 9/19 POSTOP Hospitals x MT Surg/Proc Documentation Pre/Peri/Postop Nurs Doc Liz Coates Carbon Copy Allegra Final Carbon Copy Allegra Final Carbon Copy Carbon Copy Carbon Copy Carbon Copy x x Spectrum (Home Health) Greg Hilpert Teresa O’Connell Allegra Final Allegra Final Allegra Final Carbon Copy (2-part) Allegra Final x Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell x Carbon Copy x Carbon Copy x Carbon Copy x x Carbon Copy (2-part) x x Carbon Copy (2-part) x x Carbon Copy (2-part) x Carbon Copy x Carbon Copy (2-part) Spectrum Ben Buckridge Kassi Houston Kevin Evenson Clean-up x Hospital Wide x Clean-up x Hospital Wide x PV x Clinic Spectrum Ben Buckridge Spectrum Ben Buckridge Allegra Final Allegra Final Allegra Final Allegra Final Rehab – Outpatient x Carbon Copy Carbon Copy (2-part) x x x x Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell A 1/09 4/09 Spectrum (Home Health) PV x x Allegra Final I Prog DME Packet 333-0248 x Carbon Copy (3-part) x x x PV 333-0248 Y x x x x University of Management and Technology Forms Repository Worksheet PV DME Packet Carbon Copy (2-part) x x I Spectrum Medical DME Packet Allegra Final x x Liz Coates Teresa O’Connell Spectrum Medical Spectrum Medical Allegra Final x x Kevin Langkiet Lynze Cannon x Spectrum Medical x Wade Nelson 11/18 x x x Brad Garpestad Scott Schandelson Nikki Walsh SPEC 12/18 Allegra Final x Brandi Cornwell SPEC SPEC Allegra Final x x Spectrum 333-0246 SPEC x Laboratory Hospital Wide 333-0246 333-0247 Lime Green x x Endoscopy Lab DME Packet 333-0248 POLST x x x x Allegra DME Packet DME Packet x x Emergency Dept Acute Care Durable Medical Equipment Checklist DME Packet x x Allegra Final A PV Surg/Proc Documentation Spectrum x x x x I Spectrum Medical x x Clean-up Spectrum Medical x x Teresa O’Connell X x Allegra Final x Donna Rollinson Heart & Vascular Spectrum Medical 4/19 Teresa O’Connell Teresa O’Connell Teresa O’Connell Allegra Final x Cathy Burnstein Enterprise Wide x x x Brad Garpestad x I x x x Brad Garpestad A x MedRec only Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Spectrum Clean-up x x x Brad Garpestad Spectrum X MT x MedRec only Scott Schandelson FAC 333-1382 333-0113 333-0116 Allegra PDF only Carbon Copy (2-part) A x Carbon Copy x x x x Allegra Final Carbon Copy x x x Allegra Final Allegra Final Carbon Copy (2-part) x Allegra Final Outpatient Surgery Center – ASC Linda Tschetter Jill Newbrough x A x Outpatient Surgery Center – ASC Linda Tschetter Jill Newbrough x _ X Clean-up x Women’s and Children’s Services Kristen Srna Caroline McConville x Y x _ X Clean-up x Women’s and Children’s Services Kristen Srna Caroline McConville x Y x X A x Infectious Disease Clinic Chad Bralick Amy Linder x 11/19 _ Benefis 333-0341 333-0352 CLI FAC x 2/07 _ ELECTRO Benefis Healthcare x 333-0825 FAC 4/17 ANES Hospitals x Discharge instructions, needs to be 2-part per Caroline M 333-0377 FAC 0028 FAC-0028 12/09 INST X Hospitals x 333-0377 FAC 0028 FAC-0028 INST X Hospitals x MT Liz – no longer uses 333-0394 FAC 7/16 IVCON Hospitals x MT 333-0395 FAC … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to 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University of Management and Technology Forms Repository Worksheet

University of Management and Technology Forms Repository Worksheet University of Management and Technology Forms Repository Worksheet In the attached excel spreadsheet, I am having some issues with the following: Under Form ID column E, the drop-down menu does not display all the department identifiers from the pick-list. Under Version Control column Q, the drop-down menu does not display all the proper version controls from the pick-list. When I try to filter out all patient facing forms, it is not filtering out the blanks. forms_repository.xlsx ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS Form Name New Form Name Form # New Form # Delivery Record Benefis Ambulatory Pharmacy White Original/Pharmacy copy, Yellow Delivery Copy/Obtain Patient Signature then return to Pharmacy, Pink Patient copy 005-5001 FAC 0001 FAC-0001 Delivery Record Benefis Ambulatory Pharmacy White Original/Pharmacy copy, Yellow Delivery Copy/Obtain Patient Signature then return to Pharmacy, Pink Patient copy Validation Notes 005-5001 FAC 0001 FAC-0001 Physician Order / Laboratory Test Requisition White, Yellow, Pink with no instructions. Physician Order / Lab Requisition 005-5002 CLI 2/19 ORD 005-5002 FAC 4/12 ORD Physician Order / Laboratory Test Requisition no carbon copy instructions. Downtime form. Usually print a different version from EMR Emergency Department Discharge Instructions Emergency Department Discharge Instructions Physicians Orders Scanned after discharge or deceased Senior Care Center Medication Regimen Review Stat / Now / One-Time Medication Administration Record in EHR no reason to keep form Registration Operative Nursing Assessment Doctor Appointment Card Treatment Consent Form – Pediatrics Patients Authorization for Treatment Pediatric Patients Treatment Consent Form – Pediatrics Patients Authorization for Treatment Pediatric Patients Authorization to Release Birth Announcement Information to the News Media Remove ‘Legal Health Record’ mention replace with ‘Electronic Health Record’ Mnemonic Logo(text) _ Hospitals Barcode Scanned? NextGen Document Type _ Hospitals X Hospitals Order (New) MR Reports (SCANNED) MR Reports (SCANNED) FAC 0024 FAC-0024 ERINST X Hospitals x MT FAC 0024 FAC-0024 ERINST X Hospitals x MT 005-5011 FAC 10/07 ORD Hospitals x MT 005-5012 SEN 12/16 SNMED Hospitals x MT Patient Care Documentation MT Patient Care Documentation 8/09 005-5013 10/08 005-5016 x FAC 1/10 MAR _ PREOP Health System x Hospitals x Surg/Proc Documentation MT CLI 005-5028 CLI 005-5032 FAC 0001 0001 CLI-0001 10/18 CLI-0001 CONSENT X CONSENT X 11/00 _ Hospitals x FAC 0025 FAC-0025 Hospitals x Hospitals x 7/13 I MedRec Women’s and Children’s Services MT Misc Consent/Release Clean-up Women’s and Children’s Services RELEASE X Hospitals x Misc Consent/Release MT TICKET Hospitals X Administrative Data 005-5050 FAC 6/11 TICKET Hospitals X Administrative Data FAC-0025 FAC CLI 005-5073 005-5085 FAC 005-5088 FAC 0026 FAC-0026 005-5088 FAC 0026 FAC-0026 005-5104 FAC RELEASE X x _ x _ 2/16 _ 5/05 CTHX 4/12 CONSENT X CONSENT X 7/86 8/13 FAC UNI 0005 UNI-0005 005-5133 UNI 0005 UNI-0005 FAC 0011 FAC-0011 Hospitals x RELEASE RELEASE 11/17 RELEASE X 7/12 x 005-5165 FAC 2/16 005-5172 FAC 1/00 card stock. specific to Dr Schaefer 005-5173 FAC 2/10 VanGilder ACDF & Lumbar Kardex card stock. specific to Dr VanGilder 005-5174 FAC 005-5180 005-5210 FAC 005-5228 FAC last ordered 8/22/19 last ordered 1/10/20. Created by marketing last ordered 1/28/20 last ordered 4/4/19. no instructions for carbon copy Critical Care Flowchart 2/10 005-5228 FAC 0017 FAC-0017 005-5228 FAC 0017 FAC-0017 005-5241 X Health System x Health System x MT Radiology Reports Consent/Authorizat ions Consent/Authorizat ions Expiration Documentation Expiration Documentation MT 005-5325 005-5329 005-5521 Dismissal Instructions penny checking last ordered 11/20/17. White, Yellow, Pink (No instructions) last ordered 1/21/20. Revision sent to Medrec by Reanna Brown Card Stock Card Stock Care Agreement FAC FAC PHREF x _ x 9/95 _ _ 10/19 IMPMSGDSCH 3/20 Hospitals _ UNI UNI UNI 0001 UNI-0001 UNI 0001 UNI-0001 3 per page perforated (same info as 0055980) Expiration Protocol Send to Ray with 3330652 Send to Ray with 3330652 2 per page perforated (same info as 0055931) 2 per page perforated (same info as 0055931) x PV x Y x x x x x Carbon Copy Allegra Final A Radiology x Radiology Paul Fulbright Greg Hilpert Clean-up Radiology x Radiology Paul Fulbright Greg Hilpert Clean-up x x PV Clinic Women’s and Children’s Services Allegra Final Scott Schandelson Kevin Langkiet Medical Records Joan Rand Nelson Liston x Carbon Copy Women’s and Children’s Services Kristen Srna Caroline McConville x Carbon Copy Administrative Data Patient Care Documentation Patient Care Flow Sheets Dismissal Instructions/Notes Nikki Walsh Lynze Cannon x Women’s and Children’s Services Kristen Srna Caroline McConville x x Acute Care A I x x PV x Rehab – Inpatient Other Care Coordination/CDI Care Coordination/CDI Care Coordination/CDI x x x x x x Card Stock A x Hospital Wide A x . University of Management and Technology Forms Repository Worksheet Emergency Dept Scott Schandelson Kevin Langkiet x A x Critical Care Tara Eckenstein Kevin Langkiet x x CMS Carbon Copy (2-part) CMS Carbon Copy (2-part) x x x Jill Newbrough x x Carbon Copy (2-part) Linda Tschetter Jill Newbrough x x Carbon Copy (2-part) Kristen Srna Darci Bernardi Caroline McConville Jamie Leonard x INST Healthcare x MT 1/18 ORD Health System x MT Patient Care Documentation MR Reports (SCANNED) 10/18 ORD Health System x MT 2/20 ORD Health System x MT ANES ANES 8/15 10/18 CAREAGREE x MT X Health System x Hospitals I MR Reports (SCANNED) Physician Orders PV MedRec MR Reports (SCANNED) Physician Orders A MedRec CONSENT2 Hospitals x CONSENT2 Hospitals x Hospitals x x Jamie Leonard x x Liz Coates x Liz Coates x Surgical Services Brandi Cornwell x Surgical Services Brandi Cornwell Care Agreement Clean-up Hospice & Ambulatory x Care Agreement Surgical/Procedur e Surgical/Procedur e Surgical/Procedur e Clean-up Hospice & Ambulatory x Enterprise Wide Care Coordination/CDI Care Coordination/CDI PV Radiology PV MT Surg/Proc Documentation Surg/Proc Documentation Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions MT Consent/Authorizat ions Surgical/Procedur e MT Consent/Authorizat ions Surgical/Procedur e Frequent Monitoring Record ECG RHYTYM _ Hospitals Hospitals x x MT Diagnostic Testing LATEX Hospitals x MT MT REFUSAL X HealthCare x MT HealthCare x MT CONSENTMISC X Hospitals x MT Hospitals x MT X 6/12 _ Hospitals Anesthesia Record Anesthesia Record Care Agreement ECG Rhythm Strips Patient Care Documentation Latex Allergy Assessment MR Reports (SCANNED) Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Consent/Authorizat ions Patient Progress Notes Misc Consent/Release Misc Consent/Release Misc Consent/Release Misc Consent/Release Misc Consent/Release none none none none PV A PV Women’s and Children’s Services x x x Radiology & Lab Women’s and Children’s Services Enterprise Wide x x PV x Enterprise Wide x x Y x Women’s and Children’s Services x Enterprise Wide x x Y x Revision Women’s and Children’s Services x Enterprise Wide x x Y x x Hospital Wide Y x I A I I MedRec (scan) Allegra Final x x Women’s and Children’s Services Emergency Dept Hospital Wide Women’s and Children’s Services x Hospital Wide A Senior Services x Hospital Wide Lab Women’s and Children’s Services x Laboratory Scott Schandelson Kevin Langkiet Kristen Srna Caroline McConville Wade Nelson Greg Hilpert x x Allegra Final x x x x x Hospital Wide Clean-up Clean-up x x x Senior Services x Clean-up I Clean-up Clean-up I I x x x x x A x Debbie Vance x Debbie Vance x Deborah Benner Deborah Benner Patty Harris Patty Harris Pharmacy Darci Bernardi Jamie Leonard x Allegra Final Acute Care Nikki Walsh Lynze Cannon x Allegra Final Allegra Final Allegra Final 005-5931 333-0652 FAC UNI 10/18 0008 UNI-0008 X Expiration Documentation Expiration Documentation EXPIR Hospitals x MT 3/16 EXPIR Hospitals x MT 5/18 AMA X Hospitals x AMA X Hospitals x 4/14 AMA X Hospitals x MT Administrative Data AMA X _ Hospitals x MT X Administrative Data x Administrative Data 333-0652 UNI 0008 UNI-0008 333-1254 FAC 0111 FAC-0111 Administrative Data 333-1254 005-5979 FAC FAC 0111 FAC-0111 005-5980 FAC 7/18 _ X 005-5980 FAC 12/11 _ X Expiration Protocol Expiration Protocol Leaving Hospital AMA Leaving Hospital AMA Leaving Hospital AMA Leaving Hospital AMA x Y x Y x Allegra Final A x PV x x Enterprise Wide x x x Enterprise Wide Behavioral Health Services – IP Behavioral Health Services – IP Hospital Wide A x Acute Care Nikki Walsh Lynze Cannon x Y x PV x Acute Care Lynze Cannon x Y x Kevin Langkiet x Clean-up Clean-up x Clean-up A Hospital Wide Y Clean-up x Hospital Wide Allegra Final x x Raymond Penyak x x Raymond Penyak Angela Trainor Raymond Penyak Angela Trainor x x x x x x x x x x Allegra Final Allegra Final Card Stock White Allegra Final Allegra Final 7/16 x Hospitals x MT CONSENT X ERCHEST Benefis x NG CONSENT X Benefis x NG Consent/Authoriz ations Consent/Authoriz ations Surgical/Procedur e Surgical/Procedur e . University of Management and Technology Forms Repository Worksheet Emergency Dept Documentation Demographics/Ad min/Legal Demographics/Ad min/Legal ER Chest Pain Flow Sheet A x Emergency Dept Nikki Walsh Scott Schandelson Consents Clean-up x Pediatrics – Clinic Michael Zeren Amy Linder x x Consents Clean-up x Pediatrics – Clinic Michael Zeren Amy Linder x x x Pediatrics – Clinic Michael Zeren Amy Linder x x Rheumatology Clinic Chad Bralick Amy Linder x x A Clinic x Family Medicine Clinic Megan Gimenes Amy Linder x x I Clinic x Pediatrics – Clinic Michael Zeren Amy Linder x 005-6035 CLI x _ Benefis X A x Family Medicine Clinic Megan Gimenes Amy Linder x 005-6040 CLI x _ Benefis X A x Outpatient – All Amy Linder x Clean-up x Emergency Dept Clean-up I I x x x Emergency Dept Hospital Wide Hospital Wide PV x Spectrum 333-1382 8/16 AMA X x x AMA X _ _ Hospitals x MT Administrative Data Leaving Hospital AMA Hospitals x MT Administrative Data Leaving Hospital AMA Clinic x Women’s and Children’s Services & Ambulatory Kevin Langkiet Scott Schandelson Kevin Langkiet 0061 FAC-0061 FAC 0061 FAC-0061 333-0117 SPEC 10/18 SPEC 6/17 Spectrum Medical PV x Spectrum Brad Garpestad SPEC x Spectrum Medical PV x Spectrum Brad Garpestad x Spectrum Medical BT TC Exercise Clean-up x Spectrum Brad Garpestad x Spectrum Medical BT TC Exercise Clean-up x Spectrum Brad Garpestad I x Spectrum Brad Garpestad I x Spectrum Brad Garpestad Spectrum Brad Garpestad Exercise Recommendations last ordered 4/11/17 333-0119 SPEC 0017 SPEC-0017 Exercise Recommendations Home Health Agency Outcome and Assessment Information Set (OASIS) 333-0119 SPEC 0017 SPEC-0017 Home Health Packet 333-0120 SPEC x Home Health Agency Outcome and Assessment Information Set (OASIS) No Medicate/Medicaid Coverage Home Health Packet 333-0121 SPEC x 333-0122 SPEC Spectrum Medical x 333-0123 SPEC 0020 SPEC-0020 333-0123 SPEC 0020 SPEC-0020 Spectrum Medical x _ UNI 6/11 _ 333-0126 FAC x _ last ordered 2/14/14 in EHR. Use for brand new pt reg in EHR. Use for brand new pt reg 333-0127 FAC x _ 333-0128 SPEC 0018 SPEC-0018 333-0128 SPEC 0018 SPEC-0018 DME Packet 333-0129 SPEC DME Packet 333-0130 SPEC Patient Business Services New Patient Information DME Packet 333-0130 SPEC Patient Business Services New Patient Information DME Packet 333-0130 SPEC Clean your Hands DME Packet 333-0131 PV Spectrum Medical x 333-0124 last ordered 2/14/14 x x Clean-up Spectrum Medical x Spectrum (Home Health) Donna Rollinson Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell x Jamie Leonard Teresa O’Connell x Greg Hilpert x Kevin Langkiet x Greg Hilpert x x x Heart & Vascular Cathy Burnstein x Spectrum Brad Garpestad Spectrum Medical X Clean-up x Spectrum Brad Garpestad PV X PV x Spectrum (Home Health) Spectrum Ben Buckridge Spectrum Ben Buckridge 0001 SPEC-0001 5/19 Spectrum Medical X x Spectrum Ben Buckridge 0001 SPEC-0001 11/20 Spectrum Medical X A x Spectrum Ben Buckridge SPEC 0019 SPEC-0019 x Spectrum Medical X Clean-up Spectrum (Home Health) x Spectrum Ben Buckridge DME Packet 333-0131 SPEC 0019 SPEC-0019 Spectrum Medical X Clean-up Spectrum (Home Health) x DME Packet 333-0132 SPEC 3/19 Spectrum Medical X PV Spectrum (Home Health) DME Packet 333-0132 SPEC 1/12 Spectrum Medical X PV Spectrum (Home Health) DME Packet 333-0132 SPEC 0002 SPEC-0002 4/19 DME Packet 333-0132 SPEC 0002 SPEC-0002 11/20 last ordered 8/13/18. no carbon copy instructions. Send white copy to assisted living. Use paper chart 333-0134 CLI Patient Information – Registration form 333-0135 SPEC x Referring Diagnosis Card 333-0137 FAC x last ordered 2/14/17 333-0140 last ordered 12/4/19 333-0141 333-0143 x FAC x _ Ben Buckridge Ben Buckridge x Spectrum Ben Buckridge Spectrum Ben Buckridge x Benefis Ambulatory Pharmacy (BAP) Rose Kommers Spectrum Medical X PV Spectrum (Home Health) X A Spectrum (Home Health) Hospitals X A I x Spectrum Brad Garpestad X I x Laboratory x Emergency Dept Wade Nelson Scott Schandelson Spectrum Medical _ _ x X x MT Surg/Proc Documentation Bronch Preliminary Rpt x MT Emergency Dept Documentation ER Mercy MedFlight FAC x x 333-0144 FAC 1/10 Advance Beneficiary Notice of Noncoverage (ABN) 333-0145 SPEC x 333-0153 333-0157 FAC FAC 9/05 x ERFLIGHT _ _ _ Healthcare Pre-Bypass Checklist 333-0163 FAC 5/01 _ Healthcare x Perfusion Record Discharge Instructions for Fiberoptic Bronchoscopy Discharge Instructions for Fiberoptic Bronchoscopy Autotransfusion Flowsheet 333-0164 333-0169 333-0169 333-0182 FAC 5/06 4/12 1/01 7/01. University of Management and Technology Forms Repository Worksheet PERFUSION _ _ _ Healthcare Healthcare Healthcare Healthcare x x x x MT Cardiopulmonary Arrest Record Shipping Request 333-0213 333-0218 3/18 3/09 ARREST Hospitals Health System x MT X INST Health System x MT BRONCH Spectrum Spectrum Spectrum Medical Mercy Flight Perinatal Transport Rx for Lisa Guzman, FNR, BC, DNP FAC PV A X X Hospitals A I Spectrum Medical 333-0236 FAC 4/12 DME Packet. Walker 333-0245 SPEC 12/18 Spectrum Medical DME Packet 333-0245 SPEC 6/17 Spectrum Medical Clinic Extracorporeal Perfusion Patient Care Documentation Cardiopulmonary Arrest Record Patient Care Documentation Dismissal Instructions/Notes X I I Ben Buckridge x x x Heart & Vascular Cathy Burnstein Donna Rollinson x I I I I x x x x Surgical Services Brandi Cornwell Liz Coates x A ? x Hospital Wide Other x Radiology Paul Fulbright Spectrum Ben Buckridge Ben Buckridge Allegra Surgical Services Brandi Cornwell PV Spectrum (Home Health) Women’s and Children’s Services & Spectrum (Home Health) x Spectrum Spectrum (Home Health) Women’s and Children’s Services Spectrum Ben Buckridge x Spectrum Ben Buckridge Spectrum Ben Buckridge Spectrum Ben Buckridge Spectrum Ben Buckridge 333-0246 SPEC 0003 SPEC-0003 1/19 Spectrum Medical BT DME Packet 333-0246 SPEC 0003 SPEC-0003 11/20 Spectrum Medical BT A DME Packet. carbon copy remove page reference 333-0247 SPEC 12/18 Spectrum Medical BT Prog I Spectrum (Home Health) Spectrum Ben Buckridge BT PV Spectrum (Home Health) Spectrum Ben Buckridge BT PV Spectrum (Home Health) A Spectrum (Home Health) SPEC x Spectrum Medical SPEC 0004 SPEC-0004 4/19 Spectrum Medical DME Packet 333-0248 SPEC 0004 SPEC-0004 10/20 333-0249 CLI 333-0250 FAC 0073 FAC-0073 333-0250 FAC 0073 FAC-0073 333-0303 CLI 333-0303 CLI For your baby (gift) 333-0317 FAC 0074 FAC-0074 For your baby (gift) 333-0317 FAC 0074 FAC-0074 333-0340 CLI PV Spectrum Medical BT _ Benefis NG x _ Health System X _ Health System X Medical Correspondence Patient Questionnaire POSTOP Hospitals x MT Surg/Proc Documentation Pre/Peri/Postop Nurs Doc 9/19 POSTOP Hospitals x MT Surg/Proc Documentation Pre/Peri/Postop Nurs Doc Liz Coates Carbon Copy Allegra Final Carbon Copy Allegra Final Carbon Copy Carbon Copy Carbon Copy Carbon Copy x x Spectrum (Home Health) Greg Hilpert Teresa O’Connell Allegra Final Allegra Final Allegra Final Carbon Copy (2-part) Allegra Final x Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell x Carbon Copy x Carbon Copy x Carbon Copy x x Carbon Copy (2-part) x x Carbon Copy (2-part) x x Carbon Copy (2-part) x Carbon Copy x Carbon Copy (2-part) Spectrum Ben Buckridge Kassi Houston Kevin Evenson Clean-up x Hospital Wide x Clean-up x Hospital Wide x PV x Clinic Spectrum Ben Buckridge Spectrum Ben Buckridge Allegra Final Allegra Final Allegra Final Allegra Final Rehab – Outpatient x Carbon Copy Carbon Copy (2-part) x x x x Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell A 1/09 4/09 Spectrum (Home Health) PV x x Allegra Final I Prog DME Packet 333-0248 x Carbon Copy (3-part) x x x PV 333-0248 Y x x x x University of Management and Technology Forms Repository Worksheet PV DME Packet Carbon Copy (2-part) x x I Spectrum Medical DME Packet Allegra Final x x Liz Coates Teresa O’Connell Spectrum Medical Spectrum Medical Allegra Final x x Kevin Langkiet Lynze Cannon x Spectrum Medical x Wade Nelson 11/18 x x x Brad Garpestad Scott Schandelson Nikki Walsh SPEC 12/18 Allegra Final x Brandi Cornwell SPEC SPEC Allegra Final x x Spectrum 333-0246 SPEC x Laboratory Hospital Wide 333-0246 333-0247 Lime Green x x Endoscopy Lab DME Packet 333-0248 POLST x x x x Allegra DME Packet DME Packet x x Emergency Dept Acute Care Durable Medical Equipment Checklist DME Packet x x Allegra Final A PV Surg/Proc Documentation Spectrum x x x x I Spectrum Medical x x Clean-up Spectrum Medical x x Teresa O’Connell X x Allegra Final x Donna Rollinson Heart & Vascular Spectrum Medical 4/19 Teresa O’Connell Teresa O’Connell Teresa O’Connell Allegra Final x Cathy Burnstein Enterprise Wide x x x Brad Garpestad x I x x x Brad Garpestad A x MedRec only Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Teresa O’Connell Spectrum Clean-up x x x Brad Garpestad Spectrum X MT x MedRec only Scott Schandelson FAC 333-1382 333-0113 333-0116 Allegra PDF only Carbon Copy (2-part) A x Carbon Copy x x x x Allegra Final Carbon Copy x x x Allegra Final Allegra Final Carbon Copy (2-part) x Allegra Final Outpatient Surgery Center – ASC Linda Tschetter Jill Newbrough x A x Outpatient Surgery Center – ASC Linda Tschetter Jill Newbrough x _ X Clean-up x Women’s and Children’s Services Kristen Srna Caroline McConville x Y x _ X Clean-up x Women’s and Children’s Services Kristen Srna Caroline McConville x Y x X A x Infectious Disease Clinic Chad Bralick Amy Linder x 11/19 _ Benefis 333-0341 333-0352 CLI FAC x 2/07 _ ELECTRO Benefis Healthcare x 333-0825 FAC 4/17 ANES Hospitals x Discharge instructions, needs to be 2-part per Caroline M 333-0377 FAC 0028 FAC-0028 12/09 INST X Hospitals x 333-0377 FAC 0028 FAC-0028 INST X Hospitals x MT Liz – no longer uses 333-0394 FAC 7/16 IVCON Hospitals x MT 333-0395 FAC … Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to 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