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Chart Form Creation/Revision Request (DTKH1153-A) (PDF)
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Form NameForm NumberUpdated
2013-14 Inactivated Influenza Vaccine Information Statement ConsentKH011608/22/2013
2013-14 Inactivated Influenza Vaccine Information Statement Consent (Spanish)KH01160SP9/17/2013
2013-14 Live, Intranasal Influenza Vaccine Information Statement Consent (Spanish)KH01369SP9/17/2013
2013-2014 Live, Intranasal Influenza Vaccine Information Statement ConsentKH013698/22/2013
Ablation Post-Operative OrdersKH0140411/18/2011
Acute Care Post-Fall Huddle Tool (Adult & Pediatric)DTKH10974/16/2013
Acute Coronary Syndrome Admission OrdersKH005449/26/2011
Acute Ischemic Stroke Intravenous Alteplase OrdersKH0136810/22/2012
Addendum to Electronic Record (eMR) Anesthesia RecordKH0040810/11/2012
Administration Consent for Chemotherapy/Biologic Agent with ChemotherapyKH00049-03511/18/2011
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 Comprehensive Admission History & Physical FormKH000163/26/2008
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 OrdersKH011856/18/2013
Adult Rapid Response Data FormKH0116812/14/2006
Adult Sepsis and Septic Shock Protocol - International Guidelines for Early Recognition and Management--6/3/2013
Adult Sepsis Order SetKH0122610/9/2013
Adult Subcutaneous Insulin OrdersKH011697/29/2010
Adult Transcatheter Aortic Valve Replacement (TAVR) Post-Operative OrdersKH014132/20/2012
Adult Transcatheter Aortic Valve Replacement (TAVR) Pre-Operative OrdersKH014122/17/2012
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
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 for Medical and/or Surgical TreatmentKH0004911/19/2013
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 RecordKH01084-01311/19/2013
Behavioral Health Services Mental Health/Drug & Alcohol AssessmentKH011213/16/2011
Blanket Warming Cabinet Unit LogDTKH07563/5/2014
Blood/Body Fluid Exposure Evaluation PackKH012901/4/2012
Bronchoalveolar Lavage Fluid (BAL) Analysis OrdersKH012396/30/2008
CAPD Fluid Warming Cabinet LogDTKH11894/15/2014
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 Universal Protocol/Time Out/Procedure RecordKH01084-00312/19/2012
Cardiovascular Surgery Risk Score AssessmentKH013778/23/2011
Central Venous Catheter Insertion Checklist & Procedure NoteKH01084-02011/19/2013
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 for Transfusion of Blood ProductsKH00049-0293/15/2012
Continuous Ambulatory Peritoneal Dialysis (CAPD) FlowsheetKH011197/27/2010
COPD Exacerbation Addendum to Adult Admit to Service OrderKH010322/9/2009
Cytogenetic Testing Informed Patient ConsentKH012737/6/2009
Daily Checklist for Resuscitation CartsDTKH07403/14/2011
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 ConsentKH012747/6/2009
Doctors Office Pre-Admission Testing OrdersKH010306/26/2013
Dofetilide Order FormKH006049/26/2011
Downtime Endoscopic Moderate (Conscious) Sedation RecordKH01085-002B9/28/2010
Emergency Blood ReleaseDTKH05337/29/2011
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 FormDTKH11654/28/2011
Employee Incident/Accident Report & Supervisor/Manager InvestigationDTKH11529/2/2011
Endoscopic Moderate (Conscious) Sedation RecordKH01085-002A9/3/2010
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
Gynecology Discharge SummaryKH030172/19/2013
Hand Off Communication Tool AKA Ticket to RideDTKH09523/6/2009
Heart Failure Clinical PathwayKH013252/17/2012
Hepatitis B Vaccine Consent RecordKH007111/21/2014
Hepatitis C Testing ReminderKH246453/21/2014
High Risk Antepartum FlowsheetKH012706/19/2009
HIV (Human Immunodeficiency Virus) Testing ConsentKH0139510/28/2011
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 Critical Care Admission OrdersKH0140211/18/2011
Impella 2.5 Weaning OrdersKH0140311/18/2011
Implantable Cardioverter Defibrillator (ICD) Medical Necessity DocumentationKH013907/15/2011
Incident ReportKH001062/15/2006
Individual Authorization for the Use and Disclosure of Protected Health InformationKH000435/3/2012
Individual Authorization for the Use and Disclosure of Protected Health Information - SpanishKH00043SP5/3/2012
Individual Authorization for the Verbal Disclosure of Protected Health InformationKH013589/27/2010
Infection Control Systems - Airborne PrecautionsDTKH10207/10/2009
Infection Control Systems - Contact PrecautionsDTKH10217/10/2009
Infection Control Systems - Droplet PrecautionsDTKH10227/10/2009
Information on Falls PreventionDTKH118312/22/2011
Inpatient Continuous Ambulatory Peritoneal Dialysis (CAPD) OrdersKH013213/19/2010
Interdisciplinary Patient Care PlanKH013811/26/2011
Inter-Institutional Transfer FormKH000422/28/2008
Intravenous Alteplase Administration Time Out/Procedure RecordKH01084-0215/24/2013
Intravenous and Irrigation Fluid Warming Cabinet Unit LogDTKH11904/15/2014
Intravenous Immune Globulin (IVIG) OrdersKH0130612/16/2009
Intravenous Tissue Plasminogen Activator for Stroke 3-4.5 hours Administration ConsentKH013386/22/2010
Isolation Control Systems - Enteric PrecautionsDTKH11696/16/2011
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
Low-High Memory Thermometer Refrigerator/Freezer LogDTKH0976-A2/24/2014
Medical Orders for Life-Sustaining Treatment (MOLST)/Advance Directive Discussion DocumentationKH0131912/19/2011
MFS Maternity Pre-Admission RegistrationDTMS059311/19/2008
Moderate (Conscious) Sedation RecordKH010851/19/2006
MOLST Legal Requirements for Individuals With Developmental DisabilitiesKH013867/22/2011
MRI OrdersKH010186/6/2008
MRI Pre-Scan Patient QuestionnaireKH010133/21/2014
MTHFR DNA Based Genetic Testing Informed Patient ConsentKH01274-0037/6/2009
Negative HIV Testing ResultsDTKH117910/28/2011
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) RefusalKH01394-0029/26/2011
Nephrology Cyclophosphamide Infusion OrdersKH014163/29/2012
Nephrology Progress NoteKH013078/25/2009
Nephrology Rituximab Infusion OrdersKH014173/29/2012
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 OrdersKH001671/21/2010
Obstetric Patient Screening DatabaseKH0046310/29/2008
Obstetrical Fall Risk AssessmentKH012123/4/2008
Obstetrical Induction Scheduling Form--3/5/2009
Obstetrical Oxytocin Administration OrdersKH012671/12/2012
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
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 Comprehensive Admission History & PhysicalKH00016-0018/9/2007
Pediatric Hemodialysis Unit Continuation FlowsheetKH0108911/2/2011
Pediatric Hemodialysis Unit FlowsheetKH0108810/26/2011
Pediatric Influenza Vaccination Screening & OrdersKH01183-PED22/16/2012
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 Sepsis and Septic Shock Protocol--10/3/2013
Pediatric Unfractionated Heparin OrdersKH012581/23/2009
Pediatric Warfarin OrdersKH012612/19/2009
Peripheral Intravenous Central/Midline Catheter OrdersKH005893/16/2010
Phototherapy Provider Order FormKH246363/12/2014
Pneumococcal Polysaccaride Vaccine Information Statement Consent (Spanish)KH01159SP10/19/2011
Pneumococcal Polysaccharide Vaccine Information Sheet ConsentKH011598/27/2012
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
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 ChecklistKH000884/21/2011
Pressure Ulcer Prevention & Wound Care Management Diagram, Referral & Care PlanKH013273/24/2010
Progress NoteKH000863/4/2008
Prothrombin 20210 DNA Based Genetic Testing Informed Patient ConsentKH01274-0047/6/2009
Refrigerator/Freezer Log - Food OnlyDTKH07572/24/2014
Refrigerator/Freezer Log - Medications/Specimens OnlyDTKH07582/24/2014
Release Against Medical AdviceKH004052/28/2008
Restraint OrdersKH004187/13/2011
Risk Assessment Decision Tree for Elopement/WanderingLTCC0875/28/2008
Scheduled Cesarean Section Admission OrdersKH0135110/4/2010
Scheduled Medication Administration RecordKH000729/24/2008
Sedation Protocol for Mechanically Ventilated Adult PatientsKH004257/12/2011
Sexual Assault PackKH010867/25/2012
Signature RecordKH000228/28/2007
Special Medication SheetKH000757/14/2008
Spine Orthopaedic Surgery Post-Operative OrdersKH002125/18/2011
Stroke Patient Adult Heparin Protocol Orders KH001848/4/2009
Stroke/Transient Ischemic Attack (TIA) Discharge InstructionsKH013145/11/2011
Stroke/Transient Ischemic Attack (TIA) OrdersKH003725/28/2013
Surgery Surginet Scheduling Fax FormKH030155/28/2013
Surgical History and Physical ExamKH001236/13/2008
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 RecordKH0108411/19/2013
Unstable Angina/Non-ST Elevation MI (NSTEMI) Emergency Department OrdersKH005429/26/2011
Vaccine Consent Record - AdultKH0045311/30/2010
Vaccine Consent Record - Pediatric (age <19 years)KH0110311/30/2010
Vaccine Consent Record - Pediatric (age <19 years) - Single SignatureKH01103-00211/30/2010
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
WCHOB Direct Admit Information Form--
WCHOB Physician QA Documentation Form--

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