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Form NameForm NumberUpdated
2014-2015 Live, Intranasal Influenza Vaccine Information Statement ConsentKH013699/16/2014
2014-2015 Live, Intranasal Influenza Vaccine Information Statement Consent (Spanish)KH01369SP10/14/2014
Ablation Post-Operative OrdersKH0140411/18/2011
Abscond or Leaving Against Medical AdviceKH004056/17/2014
Acute Care Post-Fall Huddle Tool (Adult & Pediatric)DTKH10974/16/2013
Acute Care Transfer FormKH000424/21/2015
Acute Coronary Syndrome Admission OrdersKH005449/26/2011
Addendum to Electronic Record (eMR) Anesthesia RecordKH0040810/11/2012
Administration Consent for Chemotherapy/Biologic Agent with ChemotherapyKH00049-03510/16/2017
Adult Acute Care Cardiac Rhythm Monitoring (Telemetry) OrdersKH002809/4/2008
Adult Acute Care Intra-Kaleida Transfer RecordKH004338/28/2008
Adult Admit to Service OrderKH005407/22/2011
Adult Alcohol Withdrawal Syndrome OrdersKH0137010/26/2010
Adult Behavioral Health Admission OrdersKH013898/16/2011
Adult Cardiac Surgery Telemetry Bed Transfer OrdersKH001053/7/2012
Adult Cardiothoracic Post-Operative OrdersKH002213/7/2012
Adult Chemotherapy OrdersKH0056610/5/2011
Adult Critical Care Admission OrdersKH006174/4/2011
Adult Critical Care Patient Plan of Care Record (KH00260) Master Code SheetKH00442-0019/22/2010
Adult Critical Care Patient Plan of Care Record Continuation SheetKH006502/23/2009
Adult Critical Care Vascular Admission OrdersKH0139110/21/2011
Adult Cystic Fibrosis OrdersKH014153/23/2012
Adult Deep Vein Thrombosis (DVT) OrdersKH002157/27/2009
Adult Emergency Department Initial Sepsis OrdersKH0122512/17/2013
Adult Factor VIIa & Factor IX Complex OrdersKH013782/28/2011
Adult Inpatient Cardiothoracic Pre-Operative OrdersKH006511/18/2012
Adult Insertion & Care of Intraosseous (IO) Device OrdersKH014185/24/2013
Adult Parenteral Nutrition OrdersKH002115/13/2010
Adult Patient Controlled Intravenous/Subcutaneous Analgesia OrdersKH005079/12/2008
Adult Patient Plan of Care RecordKH002317/12/2011
Adult Patient Plan of Care Record (KH00231) Master Code SheetKH004423/12/2010
Adult Patient Screening DatabaseKH0023911/18/2010
Adult Pneumococcal/Influenza Vaccination Screening & OrdersKH011832/16/2012
Adult Post Neurologic Intervention OrdersKH011904/23/2010
Adult Post-Coronary Intervention OrdersKH003699/26/2008
Adult Pre-Coronary Intervention OrdersKH003689/26/2011
Adult Pre-Operative OrdersKH011859/15/2015
Adult Pre-Operative Orders - Colon BundleKH248043/15/2016
Adult Protocol for Early Recognition and Management of Sepsis--2/20/2018
Adult Rapid Response Data FormKH0116812/14/2006
Adult Sepsis Order SetKH0122610/9/2013
Adult Subcutaneous Insulin OrdersKH011697/29/2010
Adult Transcatheter Aortic Valve Replacement (TAVR) Telemetry Bed Transfer OrdersKH014142/17/2012
Adult Unfractionated Heparin Weight Based Order (Non-Stroke Patient)KH0027111/17/2010
AED CheckNC031031/28/2014
Ambulatory Surgery Post-Procedure Discharge Instructions/Follow-up RecordKH0009210/28/2008
Ambulatory Surgery Unit Adult Cardiac Surgery Pre-Operative OrdersKH013923/7/2012
Ambulatory Surgical Center ChecklistNC03568A1/16/2018
Anesthesia Cocaine LetterDTKH09178/14/2006
Anesthesia RecordKH0046810/11/2012
Anesthesia Services Outpatient Pre-Procedure Provider CommunicationKH245636/18/2013
Argatroban Protocol OrdersKH0125111/13/2009
As Needed (PRN) Medication Administration RecordKH000739/24/2008
Authorization for Anesthesia ServicesKH030145/21/2013
Authorization for Autopsy (Postmortem) ExaminationKH0029811/19/2013
Authorization to Discharge Newborn to Representative Other Than the Birth MotherKH0134211/19/2013
Automated Urinalysis & Urine Pregnancy Point of Care ReportKH013406/22/2010
Bedside Universal Protocol/Time Out/Procedure RecordKH01084-0132/17/2015
Behavioral Health Services Mental Health/Drug & Alcohol AssessmentKH011213/16/2011
Blood/Body Fluid Exposure Evaluation PackKH0129011/10/2017
Bronchoalveolar Lavage Fluid (BAL) Analysis OrdersKH0123910/24/2017
Bronchodilator Protocol for Asthma and COPD ExacerbationKH007714/18/2014
Cardiac Services Patient Assessment GuideKH014112/17/2012
Cardiac Surgery Algorithm/Decision Tree: Hemodynamic Management - Low Cardiac IndexDTKH1166-0028/30/2011
Cardiac Surgery Algorithm/Decision Tree: New Onset Atrial FibrillationDTKH1166-0035/18/2011
Cardiac Surgery Protocol/Decision Tree: Hemodynamic Management - Fluid ResuscitationDTKH1166-0018/22/2011
Cardiac Surgery/Cardiac Catheterization Universal Protocol/Time Out/Procedure RecordKH01084-0035/17/2016
Cardiovascular Surgery Risk Score AssessmentKH013778/23/2011
Central Venous Catheter Insertion Checklist & Procedure NoteKH01084-0206/10/2014
Cerebrospinal Fluid (Test) Request/OrdersKH012336/17/2008
Colorectal Post-Operative OrdersKH012726/19/2009
Colorectal Pre-Operative OrdersKH012716/23/2009
Congestive Heart Failure Addendum to Adult Admit to Service OrderKH0021911/29/2011
Congestive Heart Failure and/or Myocardial Infarction Discharge QuestionnaireKH011584/19/2007
Congestive Heart Failure/Pneumonia Addendum To Adult Admit To Service OrderKH011612/9/2007
Consent Clonidine Suppression TestKH00049-22410/16/2017
Consent for Bedside ProcedureKH2480310/16/2017
Consent for Clinical Photographic RecordingKH247604/21/2015
Consent for Medical and/or Surgical TreatmentKH0004910/16/2017
Consent for Transfusion of Blood ProductsKH00049-02910/16/2017
Consent for Treatment and Payment AgreementKH002876/28/2017
Consentimiento Para Procedimiento a Pie de CamaKH24803SP4/28/2016
Consentimiento Para Tratamiento Medico y/o QuirurgicoKH00049SP10/16/2017
Continuous Ambulatory Peritoneal Dialysis (CAPD) FlowsheetKH011197/27/2010
COPD Exacerbation Addendum to Adult Admit to Service OrderKH010322/9/2009
Cytogenetic Testing Informed Patient ConsentKH0127311/10/2017
Daily Checklist for Infant WarmersNC0317611/10/2017
Debridement Procedure DescriptionKH013834/20/2011
Diabetes-Endocrinology Center - Provider Zoledronic Infusion OrderKH2459510/15/2013
Dialysis Comprehensive Interdisciplinary AssessmentKH012858/4/2009
Dialysis Unit Patient Plan of CareKH0124711/18/2009
Difficult Intubation LetterDTKH09536/22/2007
Discharge Medication History and Order (Medication Reconciliation)KH00742A6/19/2012
Discharge RecordKH00410B6/19/2009
Diverticulitis Addendum to Adult Admit to Service OrderKH0065611/10/2008
DNA Based Genetic Testing Informed Patient ConsentKH0127411/10/2017
Doctors Office Pre-Admission Testing OrdersKH010306/26/2013
Dofetilide Order FormKH006049/26/2011
Downtime Endoscopic Moderate (Conscious) Sedation RecordKH01085-002B11/10/2017
Emergency Blood Release FormDTKH05333/28/2012
Emergency Department Adult Nursing Assessment & Care PlanKH0028812/4/2009
Emergency Department Decompensated Congestive Heart Failure OrdersKH0137111/17/2010
Emergency Department Discharge InstructionsKH0002710/13/2008
Emergency Department Initial Restraint Note & AssessmentKH012657/12/2011
Emergency Department Observation Unit Discharge Instructions KH0118010/13/2008
Emergency Department Observation Unit RecordKH0117510/20/2009
Emergency Department Stroke/Transient Ischemic Attack (TIA) OrdersKH011119/7/2012
Employee Ergonomic Requisition FormDTKH11655/9/2016
Employee Health Department - Respirator Medical Evaluation Questionnaire Attachment BKH247158/4/2014
Employee Incident/Accident Report & Supervisor/Manager InvestigationDTKH11529/2/2011
Employee Meningitis Exposure ProphylaxisNC0320612/29/2014
Endoscopic Moderate (Conscious) Sedation RecordKH01085-002A11/10/2017
Endoscopic Outpatient HistoryKH011953/15/2016
Factor V Leiden DNA Based Genetic Testing Informed Patient ConsentKH01274-0017/6/2009
Family Health Care Decision Act (FHCDA) Consent Form 1KH01367-0019/3/2010
Family Health Care Decision Act (FHCDA) Consent Form 2KH01367-0029/3/2010
Family Health Care Decision Act (FHCDA) Consent Form 3KH01367-0035/12/2011
Family Health Care Decision Act (FHCDA) Consent Form 4KH01367-0045/12/2011
Family Health Care Decision Act (FHCDA) Consent Form 5KH01367-0059/3/2010
Family Health Care Decision Act (FHCDA) Consent Form 6KH01367-0069/3/2010
Family Health Care Decision Act (FHCDA) Consent Form 7KH01367-0079/3/2010
Flu Clinic History & Treatment RecordKH01264-00110/30/2009
Fragile X Syndrome DNA Based Genetic Testing Informed Patient ConsentKH01274-0027/6/2009
Functional Ambulatory Capacity Six Minute Walk TestKH013363/9/2012
General Surgical Adult Post-Operative OrdersKH011631/18/2012
GVI Pre-Procedure OrdersKH245846/18/2013
Gynecology Discharge SummaryKH030172/19/2013
Hand Off Communication Tool AKA Ticket to RideDTKH09529/19/2017
Heart Failure Clinical PathwayKH013252/17/2012
Hepatitis B Vaccine Consent RecordKH007119/20/2016
High Risk Antepartum FlowsheetKH012706/19/2009
HIV (Human Immunodeficiency Virus) Testing ConsentKH0139510/28/2011
HIV (Human Immunodeficiency Virus) Testing EducationNC032156/16/2015
HIV Testing Consents - multi-language - use conjunction w Language Line and/or InterpreterNYSDOH Website
Home Medication History Addendum & Orders eMR AddendumKH01407-0032/21/2012
Hospice Admit to Service OrdersKH012237/28/2009
Impella 2.5 Addendum to Adult Critical Care Admission OrdersKH014022/17/2015
Impella 2.5 Weaning OrdersKH0140311/18/2011
Implantable Cardioverter Defibrillator (ICD) Medical Necessity DocumentationKH013907/15/2011
Inactivated Influenza Vaccine Information Statement ConsentKH011609/16/2016
Inactivated Influenza Vaccine Information Statement Consent (Spanish)KH01160SP9/16/2016
Incident ReportKH0010611/10/2017
Individual Authorization for the Use and Disclosure of Protected Health InformationKH0004311/10/2017
Individual Authorization for the Use and Disclosure of Protected Health Information - SpanishKH00043SP11/10/2017
Individual Authorization for the Verbal Disclosure of Protected Health InformationKH013589/27/2010
Infection Control Systems - Airborne PrecautionsDTKH10201/17/2017
Infection Control Systems - Contact PrecautionsDTKH10211/17/2017
Infection Control Systems - Droplet PrecautionsDTKH10221/17/2017
Information on Falls PreventionDTKH118312/22/2011
Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) OrdersKH013213/19/2010
Instructions for Voluntary Respirator UseNC031838/4/2014
Interdisciplinary Patient Care PlanKH013811/26/2011
Intravenous Immune Globulin (IVIG) OrdersKH013064/2/2018
Intravenous Tissue Plasminogen Activator for Stroke 3-4.5 hours Administration ConsentKH013386/22/2010
Ischemic Stroke/TIA OrdersKH003723/14/2014
Isolation Control Systems - Enteric/Bubble and Bleach Contact PrecautionsDTKH11691/17/2017
Kaleida Health Emergency Department Confidential Fax Report (SBAR)DTKH11512/2/2011
Lab Downtime FormS004999/21/2010
Late Preterm Infant Supplemental Newborn Nursery OrdersKH013182/24/2010
Latex Allergy Screening ToolKH0118612/6/2010
Mantoux TB Skin TestDTKH071711/10/2017
Maternity Pre-Admission RegistrationDTMS059311/10/2017
Medical Orders for Life-Sustaining Treatment (MOLST)/Advance Directive Discussion DocumentationKH0131912/19/2011
Medication Release and Counseling AcknowledgementNC032051/20/2015
Moderate (Conscious) Sedation RecordKH0108511/10/2017
MOLST Legal Requirements for Individuals With Developmental DisabilitiesKH0138610/20/2015
MRI OrdersKH0101811/10/2017
MRI Pre-Scan Patient QuestionnaireKH0101311/10/2017
MTHFR DNA Based Genetic Testing Informed Patient ConsentKH01274-0037/6/2009
Negative HIV Testing ResultsDTKH11796/16/2015
Neonatal Erythromycin Treatment (Newborn Purulent Conjunctivitis Prevention) RefusualKH01394-0019/26/2011
Neonatal Intensive Care Unit Interdisciplinary Discharge PlanKH011649/3/2009
Neonatal Vitamin K Treatment (Vitamin K Deficiency Bleeding Prevention) RefusalKH01394-0027/15/2014
Nephrology Cyclophosphamide Infusion OrdersKH014163/29/2012
Nephrology Progress NoteKH013078/25/2009
Nephrology Rituximab Infusion OrdersKH014174/2/2018
Neurosurgery Orders Carotid StentKH006286/6/2005
Newborn Nursery Neonate Car Seat Challenge Results for ParentsKH012214/16/2008
Observation Asthma OrdersKH011787/25/2012
Observation Back Pain OrdersKH030077/11/2012
Observation Chest Pain OrdersKH011777/24/2012
Observation Community Acquired Pneumonia OrdersKH030067/18/2012
Observation Congestive Heart Failure OrdersKH011767/23/2012
Observation COPD Exacerbation OrdersKH030087/11/2012
Observation Dehydration OrdersKH030057/11/2012
Observation Diverticulitis OrdersKH030047/11/2012
Observation Gastroenteritis OrdersKH030027/11/2012
Observation General OrdersKH030037/11/2012
Observation Pyelonephritis OrdersKH030017/18/2012
Observation Syncope OrdersKH012698/2/2012
Observation Transient Ischemic Attack (TIA) OrdersKH013578/3/2012
Obstetric Admission OrdersKH0016711/10/2017
Obstetric Patient Screening DatabaseKH0046310/29/2008
Obstetrical Fall Risk AssessmentKH012123/4/2008
Obstetrical Induction Scheduling Form--3/5/2009
Obstetrical Oxytocin Administration OrdersKH0126711/10/2017
Obstetrics Discharge SummaryKH030162/21/2013
Operating/Procedure Rooms Request for Immediate Pathology EvaluationKH012866/9/2009
Orders (Plain Paper)KH00533-A12/20/2010
Orthopaedic Blood Product Transfusion OrdersKH014051/19/2012
Orthopaedic Joint Venture Functional Assessment ScoreKH013325/24/2010
Orthopaedic Joint Ventures Ticket to DischargeKH013338/20/2013
Orthopaedic Pre-Op Teaching Class Interdisciplinary Patient/Resident/Family Education RecordKH00024-5024/27/2010
Outpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) Monthly NotesKH013761/7/2011
Outpatient Hemodialysis Fourth Treatment OrdersKH012898/26/2009
Pacemaker or ICD Implant Post-Operative OrdersKH0109511/18/2011
Pain/Fatigue/Distress SurveyKH246329/16/2014
Patient Allergy ProfileKH012458/26/2008
Pediatric Admit To Service OrderKH0058010/15/2008
Pediatric Asthma Home Management Plan of CareKH012976/23/2009
Pediatric Asthma Home Management Plan of Care (Spanish)KH01297SP2/15/2011
Pediatric Consent ColonoscopyKH00049-23210/16/2017
Pediatric Consent EGDKH00049-22610/16/2017
Pediatric Consent EGD & ColonoscopyKH00049-23110/16/2017
Pediatric Consent EGD With Possible BandingKH00049-22810/16/2017
Pediatric Consent EGD With Possible DilationKH00049-22710/16/2017
Pediatric Consent EGD With Possible Foreign Body RemovalKH00049-22910/16/2017
Pediatric Consent for Gastrostomy Tube ChangeKH00049-23310/16/2017
Pediatric Consent for Percutaneous Liver BiopsyKH00049-23410/16/2017
Pediatric Consent Rectal Suction BiopsyKH00049-23010/16/2017
Pediatric Hemodialysis Unit Continuation FlowsheetKH0108911/2/2011
Pediatric Hemodialysis Unit FlowsheetKH0108810/26/2011
Pediatric Influenza Vaccination Screening & OrdersKH01183-PED212/16/2014
Pediatric Low Molecular Weight Heparin OrdersKH012571/23/2009
Pediatric Narcotic Sedative Weaning OrdersKH012551/22/2009
Pediatric Opioid Naive Patient Controlled Analgesia (PCA) OrdersKH01132A11/21/2008
Pediatric Opioid Tolerant Patient Controlled Analgesia (PCA) OrdersKH01132B11/21/2008
Pediatric Pneumococcal Vaccination Screening & OrdersKH01183-PED13/6/2013
Pediatric Severe Sepsis Screening and Emergency Management Protocol--5/7/2018
Pediatric Surgery Order SheetKH005832/28/2008
Pediatric Unfractionated Heparin OrdersKH012581/23/2009
Pediatric Warfarin OrdersKH012612/19/2009
Peripheral Intravenous Central/Midline Catheter OrdersKH005893/16/2010
Phototherapy Provider Order FormKH2463611/10/2017
Pneumococcal Polysaccharide Vaccine Information Sheet ConsentKH011598/27/2012
Pneumococcal Polysaccharide Vaccine Information Statement Consent (Spanish)KH01159SP10/19/2011
Pneumonia Addendum to Adult Admit to Service OrderKH002831/18/2012
Post Cardiac Arrest Therapeutic Hypothermia SetKH0132911/19/2013
Post Falls Tip SheetNC031061/24/2014
Post Mortem DocumentationKH002383/25/2014
Post-Operative Cesarean Section OrdersKH001661/9/2012
Postpartum Depression Department of Nursing Standard Care PlanKH01142-06311/1/2008
Postpartum Vaginal Delivery OrdersKH001651/9/2012
Post-Procedure Record (Downtime)KH01084-POST6/8/2016
Practitioner/Provider Fax Request for Patient Information From Kaleida HealthKH245603/8/2013
Pre-Admission Questionnaire (OCH)WCHOB-29010/26/2017
Pre-Admission Testing Orders For Nurse Practitioners at Pre-Testing SitesKH010316/7/2005
Pregnancy AttestationKH0130011/10/2009
Pregnancy Attestation - Imaging ServicesKH01300-0017/29/2011
Pre-Operative Medical Evaluation ConsultKH012276/10/2008
Pre-Operative/Pre-Procedure ChecklistKH000884/30/2015
Pre-Procedure Record (Downtime)KH01084-PRE6/8/2016
Pressure Ulcer Prevention & Wound Care Management Diagram, Referral & Care PlanKH013273/24/2010
Primary Care Physician Letter of SupportKH248784/17/2018
Prothrombin 20210 DNA Based Genetic Testing Informed Patient ConsentKH01274-0047/6/2009
Respirator Fit-Test Attachment CKH247168/4/2014
Restraint OrdersKH004187/13/2011
Risk Assessment Decision Tree for Elopement/WanderingLTCC0874/16/2012
Scheduled Cesarean Section Admission OrdersKH0135111/10/2017
Scheduled Medication Administration RecordKH000729/24/2008
Sedation Protocol for Mechanically Ventilated Adult PatientsKH004257/12/2011
Sexual Assault PackKH0108611/10/2017
Signature RecordKH000228/28/2007
Southtowns Consent for Medical and/or Surgical TreatmentSSC0004910/19/2017
Southtowns Consent for Treatment & Payment AgreementSSC002876/17/2016
Southtowns Surgery Scheduling Fax FormSSC10006/17/2016
Special Medication SheetKH000757/14/2008
Spine Orthopaedic Surgery Post-Operative OrdersKH002125/18/2011
Stroke - Alteplase Administration Verification and Monitoring RecordKH1084-0218/15/2017
Stroke Patient Adult Heparin Protocol OrdersKH001843/13/2014
Stroke, Acute Ischemic Intravenous Alteplase OrdersKH013685/16/2017
Surgery Surginet Scheduling Fax FormKH0301511/10/2017
Surgical History & Physical ExamKH001236/13/2008
Telemedicine ConsentKH00049-21810/16/2017
Trial Of Labor After Cesarean Section (TOLAC) Patient Consent FormKH0111811/9/2005
Trial Of Labor After Cesarean Section (TOLAC) Patient Information SheetKH0111711/9/2005
UBMD Pulmonary Medicine Follow-up Patient NoteKH014092/17/2012
UBMD Pulmonary Medicine Initial Patient NoteKH014082/17/2012
Universal Protocol/Time Out/Procedure RecordKH010845/17/2016
Unstable Angina/Non-ST Elevation MI (NSTEMI) Emergency Department OrdersKH005429/26/2011
Vaccine Consent Record - AdultKH0045312/7/2015
Vaccine Information StatementsCDC Website
Vascular Interventional Radiology Post-Procedure Discharge Instructions/Follow-up RecordKH0053510/28/2008
Vascular Interventional Radiology Post-Procedure OrdersKH005376/25/2008
Vascular Interventional Radiology Pre & Intra Procedure OrdersKH012369/11/2009
Voluntary Discharge of Infant/Pediatric Patient to Other Than the Natural ParentKH245836/21/2013
WCHOB Direct Admit Information Form--
WCHOB Physician QA Documentation Form--
Welcome to Oishei Children's Hospital Ambulatory Surgical CenterNC035681/16/2018

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