Questionnaire to Customize Your Hospital MH Procedure Manual
Hospital Name______Contact Name______
Email ______Phone Number ______
(ORDER CANNOT BE PROCESSED UNLESS ABOVE INFORMATION IS FILLED IN)
We recommend the Hospital MH Procedure Manual you ordered to be customized. In order to do this, we need to ask you a series of questions. We are aware each hospital is not set up exactly the same, so you may find that some of the questions may not pertain to you.
MH Cart/Kit
Where is the MH Cart/Kit located? (pages 21, 35, 36)
Location : ______
What type of container on the MH cart/kit contains the nursing supplies? (i.e. Big Red Bag) (page 32)
Location : ______
Cold Supplies
Where is the inpatient refrigerator located containing the anesthesia cold supplies? (pages 21, 34, 35)
Location : ______
Where is the refrigerator located containing nursing supplies for an MH Crisis? (pages 25, 34, 35)
Location : ______
Where is the location of refrigerator containing the Regular Insulin? (pages 21, 34)
Location : ______
IMPORTANT PHONE NUMBERS
Day Phone # (page 17, 28)
Beeper # (page 28)
Night/Weekend/Holiday Phone # (page 28)
Respiratory Therapist Voice Beeper # (page 26)
Anesthesia Care Provider (page 27)
Day Phone #
Day Beeper #
Night/Weekend/Holiday Voice Beeper #
Anesthesia Technical Assistant (ATA) (page 27)
Day Phone #
Night/Weekend/Holiday Voice Beeper #
Anesthesia Equipment Tech (page 27)
Day Phone #
Day Beeper #
Night/Weekend/Holiday Phone #
PACU Charge Nurse Phone #
Various Lab Phone #’s (page 28)
Blood Gas Lab Phone #
Chemistry Lab Phone #
Blood Bank Phone #
Hematology Lab Phone #
Ice Machine
Where is the ice machine located? (pages 21, 25, 35)
Location : ______
What type of container does your hospital use to fill with ice? (pages 21, 25—3 places)
Container Type: ______
Where is the container to fill with ice located? (pages 21, 25—2 places)
Location : ______
Miscellaneous
After hours, where is the Equipment Room key located? (page 22)
Location: ______
Where is the defibrillator located? (page 23)
Location : ______