GMC NURSING POC – EMR

Electronic Forms / Flowchart / Paper
1.  Present on Admission Form
2.  Prevention of Aspiration Pneumonia Screening Form
3.  Venous Thromboembolism (VTE) Assessment & Prophylaxis Form
4.  Vaccine Screening & Administration Form
5.  Suicide Assessment
6.  Active surveillance Cultures(ASC) MRSA Admission Screening
7.  Admission Patient / Family Education Record
8.  Interdisciplinary Patient / Family Education Record
9.  Personal Essential List/ Transfer Information
10.  Pre –Angio Checklist
11.  Pre-operative Checklist
12.  Patient Hand Off Passport
13.  MRI Questionnaire
14.  Interdisciplinary Plan of Care (14 pages)
15.  Post-Mortem Release & Receipt for Body
16.  Leaving the Hospital Against Medical Advice
17.  Patient Certification (Heart Cath Recovery)
18.  Outcome notes for outpatient surgery ( OPS)
19.  Heart Cath DC Instruction (Heart Cath Recovery)
20.  Home Care Instruction and Procedure (Heart Cath Recovery) / 1.  Initial Interview Flowchart
2.  Patient Care Daily Flowchart (MS /TELE)
3.  Nursing Assistant Daily Flowchart
4.  Discharge Summary Flowchart
5.  Restraint Flowchart Q 2H
6.  Post Restraint Flowchart
7.  Blood Products Flowchart
8.  PCA Flowchart q 4 hours
9.  Pre-Procedure Assessment Checklist I (Heart Cath Recovery & OPS)
10.  Pre Procedure Assessment Checklist II (Heart Cath Recovery & OPS)
11.  Hearth Cath Daily Flowchart (Heart Cath) / 1.  All Physician Orders
2.  All Consents
3.  Medication Reconciliation
4.  Core Measures
5.  Wound Care Assessment (with photo)
6.  Blood Transfusion Consent and Refusal Form
7.  Code Blue
8.  Daily Stroke Scale/NIHSS
9.  Anticoagulant Record
10.  HIV Consent and Refusal
11.  Blood Dispense Record
12.  Consent for Release of Information
13.  PICC Line Flowsheet
14.  TB Skin Test
15.  Transfusion Reaction Report
16.  TPN Form
17.  CAPD Flowsheet
18.  Colostomy Care
19.  Diabetic Education
20.  Drug Interaction
21.  Incident Reports
22.  DNR/No Code Form
23.  Property Loss Report
24.  Facility Transfer Form – Referral for Continuity of Pt Care

GMC-ANCILLARY

Department / Electronic Forms / Flowchart
1.  Dietary / 1.  Nutrition Assessment / 1.  Nutrition Re-assessment
2.  Speech / 1.  Swallow Evaluation
2.  Modified Barium Swallowing Report
3.  Speech Eval
4.  Speech DC Summary / 1.  Speech Progress Notes
3.  OT / 1.  Acute OT Evaluation
2.  OT Discharge summary / 1.  OT Progress notes
2.  OT weekly Eval
4.  PT / 1.  Inpatient Evaluation
2.  Cardiac Rehab Evaluation
3.  Acute PT Discharge Note
4.  Outpatient Surgery Evaluation / 1.  PT Progress notes
2.  PT Weekly Re-Evaluation
5.  Social Services / None / 1.  Acute Care Social Services
6.  Case Management / 1.  Discharge Plan / 1.  Acute Care Case Management (same as Social Services Flowchart)
7.  RT / None / 1.  Progress Notes
2.  Bipap Record
3.  Ventilator
4.  O2 Setup Record
8.  Radiology / 1.  Patient Hand Off Passport
2.  Radiology Notes / None
9.  Lab / 1.  Transfusion Reaction Report / None
10.  Admitting / 1.  Personal Essential List/ Transfer Information / None