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Form NameForm NumberUpdated
2014-15 Inactivated Influenza Vaccine Information Statement ConsentKH011609/16/2014
2014-2015 Inactivated Influenza Vaccine Information Statement Consent (Spanish)KH01160SP10/14/2014
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 ChemotherapyKH00049-03511/18/2011
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 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 OrdersKH014127/16/2012
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 TreatmentKH000497/21/2015
Authorization to Discharge Newborn to Representative Other Than the Birth MotherKH0134211/19/2013
Automated Urinalysis & Urine Pregnancy Point of Care ReportKH013406/22/2010
Autorizacion Para Tratamiento Medico y/o QuirurgicoKH00049SP5/11/2015
Bedside Universal Protocol/Time Out/Procedure RecordKH01084-0132/17/2015
Behavioral Health Services Mental Health/Drug & Alcohol AssessmentKH011213/16/2011
Blanket Warming Cabinet Unit LogDTKH07564/21/2015
Blood/Body Fluid Exposure Evaluation PackKH012905/20/2014
Bronchoalveolar Lavage Fluid (BAL) Analysis OrdersKH012392/17/2015
Bronchodilator Protocol for Asthma and COPD ExacerbationKH007714/18/2014
CAPD Fluid Warming Cabinet Unit LogDTKH11894/21/2015
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 RecordKH01084-0036/10/2014
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 for Clinical Photographic RecordingKH247604/21/2015
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 Infant WarmersNC031766/17/2014
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 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 FormDTKH11654/28/2011
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 RecordKH01085-002A9/3/2010
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
GVI Pre-Procedure OrdersKH245846/18/2013
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 RecordKH007111/20/2015
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
Incident ReportKH001066/1/2012
Individual Authorization for the Use and Disclosure of Protected Health InformationKH000432/4/2015
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 PrecautionsDTKH102012/17/2014
Infection Control Systems - Contact PrecautionsDTKH102112/17/2014
Infection Control Systems - Droplet PrecautionsDTKH102212/17/2014
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 Alteplase Administration Time Out/Procedure RecordKH01084-0215/24/2013
Intravenous and Irrigation Fluid Warming Cabinet Unit LogDTKH11904/21/2015
Intravenous Immune Globulin (IVIG) OrdersKH013065/20/2014
Intravenous Tissue Plasminogen Activator for Stroke 3-4.5 hours Administration ConsentKH013386/22/2010
Ischemic Stroke/TIA OrdersKH003723/14/2014
Isolation Control Systems - Enteric PrecautionsDTKH116912/17/2014
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-A4/21/2015
Mantoux TB Skin TestDTKH07178/26/2014
Medical Orders for Life-Sustaining Treatment (MOLST)/Advance Directive Discussion DocumentationKH0131912/19/2011
Medication Release and Counseling AcknowledgementNC032051/20/2015
MFS Maternity Pre-Admission RegistrationDTMS059311/19/2008
Moderate (Conscious) Sedation RecordKH010855/20/2014
MOLST Legal Requirements for Individuals With Developmental DisabilitiesKH013866/17/2014
MRI OrdersKH010186/6/2008
MRI Pre-Scan Patient QuestionnaireKH010138/1/2014
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 OrdersKH014175/20/2014
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
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 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 Sepsis and Septic Shock Protocol--10/3/2013
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 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
Practitioner/Provider Fax Request for Patient Information From Kaleida HealthKH245603/8/2013
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
Pressure Ulcer Prevention & Wound Care Management Diagram, Referral & Care PlanKH013273/24/2010
Prothrombin 20210 DNA Based Genetic Testing Informed Patient ConsentKH01274-0047/6/2009
Refrigerator/Freezer Log - Food OnlyDTKH075712/16/2014
Refrigerator/Freezer Log - Medications/Specimens OnlyDTKH07584/21/2015
Respirator Fit-Test Attachment CKH247168/4/2014
Restraint OrdersKH004187/13/2011
Risk Assessment Decision Tree for Elopement/WanderingLTCC0874/16/2012
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 OrdersKH001843/13/2014
Stroke, Acute Ischemic Intravenous Alteplase OrdersKH013685/19/2015
Stroke/Transient Ischemic Attack (TIA) Discharge InstructionsKH013145/11/2011
Surgery Surginet Scheduling Fax FormKH0301510/15/2013
Telemedicine ConsentKH00049-21812/16/2014
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/Post-Procedure Record (Downtime)KH01084-POST6/10/2014
Universal Protocol/Time Out/Pre-Procedure Record (Downtime)KH01084-PRE6/10/2014
Universal Protocol/Time Out/Procedure RecordKH010846/10/2014
Unstable Angina/Non-ST Elevation MI (NSTEMI) Emergency Department OrdersKH005429/26/2011
V4 Procedure Area Booking InformationKH246838/19/2014
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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Any recently revised Kaleida Health form that is a permanent part of the medical record has a "tab" designation at the bottom center of the form. In most cases, this tab is the category under which you will find your form on this page.

For Kaleida Health related forms questions, please contact Marise Grosenbaugh at mgrosenbaugh@kaleidahealth.org or at 878-7707, or Betsy Koch at ekoch@kaleidahealth.org or 859-7711. For technical issues, email the Web Team.