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Department of Medicine

Acute Care

 

Templates

temp01.htm

temp02.htm

 

Organizational Charts

 

orgch99.htm

PTS_ABC

 

Telephone Features

features.htm

feature2.htm

 

Practice Guidelines

acute_practice.htm

 

Screening

health_screen_outline.htm

 

Hormone Replacement Therapy

hrt.htm

 

Department Forms

apcc_dcj.jpg

apcc_discharge.jpg

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doctors_orders.jpg

ekg_request.jpg

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glucose_strips_request.jpg

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Government Forms

3750-17.pdf  MIR01

3750-18.pdf  MIR02

3750-19.pdf  MIR03

5100-14.pdf  Workplace Monitoring Plan

5100-15.pdf  Medical Surveillance Questionnaire

5100-17.pdf  Heat Stress Monitoring Sheet

5102-7.pdf     Log of Navy Injuries and Occupational Illnesses

5102-9.pdf     OpNav Safety Report

5200-5A.pdf   Planning Calendar

5527-19.pdf   Desk Journal

A1045.pdf      Army Ideas for Excellence

a1260_r.pdf   Telecon Item Record

a1559_r.pdf   Inspector General Action Request

A1900.pdf      Conversion Mean to Sidereal

A1901.pdf      Conversion Sidereal to Mean

a1971_5r.pdf Unit Radiation Dose Record

A2173.pdf      Statement of Medical Examination and Duty Status

a2789_2r.pdf Medical Summary Report

A2823.pdf      Sworn Statement

a3081_r.pdf   Periodic Medical Examination Exemption

a3083_r.pdf   Medical Exam for Certain Geographical Areas

a3085_r.pdf   Expert Field Medical Badge Qualification

A3349.pdf      Physical Profile

A3365.pdf      Authorization for Medical Warning Tag

A3437.pdf      Certificate of Medical Examination Nonappropriated

A3586.pdf      Report of Professional Officer of the Day

A3647.pdf      Inpatient Cover Sheet

A3666.pdf      Statement of Physical Ability for Light Duty

a3711_r.pdf   Alcohol and Drug ADAPCP Resource and Performance

A3761.pdf      Community Health Nursing Activities

A3762.pdf      Community Health Nursing Family Record

A3763.pdf      Community Health Nursing Case Referral

A3821.pdf      Report of Administrative Officer of the Day

A3888.pdf      Nursing Assessment

a3888_2.pdf   Medical Record Nursing Care Plan

a3888_3.pdf   Medical Record Nursing Discharge Summary

a3889_1.pdf   Nursing 24 hour Report

a3897_r.pdf    Tuberculosis Registry

A3947.pdf       Medical Evaluation Board Proceedings

A3949.pdf       Controlled Substances Record

A3950.pdf       Flowsheet for Vital Signs and Other Parameters

A3981.pdf       Transfer of Patient

A3982.pdf       Medical and Dental Appointment

A3984.pdf       Dental Treatment Plan

A4029.pdf       Patients Clearance Record

a4036_r.pdf    Medical and Dental Preparation for Overseas Movement

A4186.pdf       Medical Recommendation for Flying Duty

A4221.pdf       Diabetic Record

a4254_r.pdf    Request for Private Medical Information

a4352_1r.pdf  Request Medicolegal Examination

a4352_r.pdf    Request Medicolegal Examination

a4359_r.pdf    Authorization Psychiatric Treatment

a4460_r.pdf    Army Law Library Shelf List

a4466_r.pdf    Patient Progress Report

A4677.pdf       Therapeutic Documentation Care Plan

A4678.pdf       Therapeutic Documentation Care Plan Medications

a4691_r.pdf    Initial Application for Clinical Privileges

A4700.pdf       Supplemental Medical Data

a4711_r.pdf    Statement of Law Violations

A4753.pdf       Notice of Unsafe or Unhealthful Working Condition

A4755.pdf       Employee Report of Alleged Unsafe or Unhealthful

a4787_1.pdf    Request Evaluation Dependent Medical/Educational

a4843_r.pdf     Guest Attendance Sheet

a4881_4r.pdf   Power of Attorney

a5006_r.pdf     Authorization for Disclosure of Information

a5007a_r.pdf   Allergy Immunotherapy Record

A5008.pdf        Telephone Medical Advice Consultation Record

A5072.pdf        Emergency Action Statement

a5142_r.pdf      Inspector General Action Request System

A5179.pdf         Preop/Postop Nursing Document

a5181_r.pdf      Screening Note of Acute Medical Care

A5184.pdf         Consumer Complaint

a5187_r.pdf      Application for Respite Caregivers

a5188_r.pdf      Med Report Cert Disability Care

a5189_r.pdf      Application for Respite Care

a5190_r.pdf      Clinician’s Information

a5191_r.pdf      Information on Individual with Disability

a5195_r.pdf      Health Data Immunizations

a5275_r.pdf      Time Study Record

a5276_r.pdf       Program Management Data

a5277_r.pdf       Operational Audit Data

a5278_ra.pdf     Work Sampling Record

a5278_rb.pdf     Work Sampling Computations

a5441_3a.pdf    Evaluation of Privileges Internal Medicine and Subsp

a5551_r.pdf       Spirometry Flow Sheet

a5569_r.pdf       INH Flowsheet

A5571.pdf          Master Problem List

a5611_r.pdf       Document Summary

a5624_r.pdf       Defibrillator Inspection Record

a5841_r.pdf       Special Instructions Power of Attorney

a5862_r.pdf       Army Exceptional Family Member Summary

A6.pdf                 Duty Roster

a705_a.pdf         Army Physical Fitness Test Scorecard

a705_b.pdf         Army Physical Fitness Test Scorecard

a705_c.pdf         Army Physical Fitness Standards Situp

a705_d.pdf         Army Physical Fitness Standards Pushup

A7095.pdf          ADAPCP Outpatient Discharge Summary

A7096.pdf          ADAPCP Outpatient Plan

A7097.pdf          ADAPCP Outpatient Problem List

A7098.pdf          ADAPCP Outpatient Treatment Plan

a7099_a.pdf      Social Support

a7099_b.pdf      Thought Processes

a7279_1r.pdf     EEO Resolution Assessment

a7279_r.pdf       EEO Complaint Form

A7389.pdf          Medical Record Anesthesia

ChargeDD0458.pdf   Charge Sheet

CorrectionDD0149.pdf   Application Correction Military Record

D1351.pdf           Travel Voucher

d1351_2.pdf        Travel Voucher or Subvoucher

d1351_2c.pdf      Travel Voucher or Subvoucher

D1572b.p   df       Test Results

D2161.pdf            Civilian Referral

D2341.pdf            Report of Animal Bite

D2343.pdf            Veterinary Health Record

D689.pdf               Individual Sick Slip

D771.pdf               Eyewear RX

D792.pdf               24 hour I and O

DD0093.pdf           Record of Emergency Data

DD0689.pdf           Individual Sick Slip

DD0739.pdf           Register of Patients

DD0771.pdf           Eyewear RX

DD0877.pdf           Request for Med/Dental Records or Info

DD0877-1.pdf        Request for Med/Dental Records from National

DD0890.pdf           Record of Identification Processing

DD0891.pdf           Record of Identification Processing Dental Chart

DD0893.pdf           Record of Identification Processing Anatomical

DD0894.pdf           Record of Identification Processing Fingerprint

DD1569.pdf           Incident Complaint Form

DD1723.pdf           Flow Process Chart

DD2005.pdf           Privacy Act Health Care Records      

DD2030.pdf          Activity Task List

DD2138.pdf          Request for Transfer of Outpatient Record

DD2161.pdf          Referral for Civilian Care

DD2215.pdf          Reference Audiogram

DD2216.pdf          Hearing Conservation

DD2341.pdf          Report of Animal Bite

DD2343.pdf          Veterinary Health Record

DD2369.pdf          MERB Cycloplegic Refraction

DD2370.pdf          MERB 3Day BP and Pulse

DD2372.pdf          MERB Statement of Present Health

DD2374.pdf          MERB Heart Murmur

DD2378.pdf          MERB Headaches

DD2379.pdf          MERB Head Injury

DD2380.pdf          MERB Sleepwalking

DD2381.pdf          MERB Motion Sickness

DD2382.pdf          MERB Allergies

DD2480.pdf          MERB Dental

DD2489.pdf          MERB Red/Green

DD2492.pdf          MERB History

DD2493-1.pdf       Asbestos Exposure

DD2493-2.pdf       Asbestos Periodic Medical

DD2499.pdf          Health Care Practitioner Action Report

DD2526.pdf          Case Abstract Malpractice

DD2527.pdf          CHAMPUS Liability

DD2632.pdf          MERB Body Fat

DD2697.pdf          Report of Medical Assessment

DD2770.pdf          Abbreviated Medical Record

DD2792.pdf          Instructions Exceptional Family Member

DD2795.pdf          Pre-Deployment Health Assessment

DD2796.pdf          Post-Deployment Health Assessment

DD2797S.pdf        TSP Enrollment

DD2807-1.pdf        Report of Medical History

DD2807-2.pdf        Instructions for Medical History

DD2808.pdf           Report of Medical Examination

DD2813.pdf           Reserve Dental

S504.pdf                Medical Record History 1

S505.pdf                Medical Record History 2

S506.pdf                Medical Record Physical

S507.pdf                Continuation

S516.pdf                Operation Report

S527a.pdf              Group Muscle Strength           

S527b.pdf              Group Muscle Strength  (continued)         

S530.pdf                Neurological Exam

S535.pdf                Newborn

S536.pdf                Pediatric Nursing

S538.pdf                Pediatric Family History

S539.pdf                Abbreviated Medical Record

S558.pdf                Emergency Care and Treatment Doctor

S600.pdf                600

S601.pdf                Immunization Record

 

State of Washington Forms

acute_washington.htm