Child Health

• Asthma card - child care, Allergy and Asthma Foundation of America

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Endocrine

Diabetes Mellitus

• Insulin Sliding Scale
  • Insulin Sliding Scale Inpatient Form (WR) [WORD 52k]
  • SSI MAR Agressive (WR) [WORD 131k]
  • SSI MAR Back (WR) [WORD 88k]
  • SSI MAR Custom (WR) [WORD 155k]
  • SSI MAR Mild (WR) [WORD 131k]
  • SSI MAR Mod (WR) [WORD 132k]

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Hemataology

• Blood Transfusion Consent (WR) [PDF 315k]

Prevention/Health Care Delivery

• Elder Exam PCC Comprehensive (IHS 865) [PDF 643k]
• PCC+ Web Page, Many Templates Available
• Prenatal assessment: ETOH, substances, Domestic Violence [PDF 24k]
• Tobacco Cessation Chart Form: Five A's
  • Ask, Advise, Assess, Assist, Arrange [PDF 18k]
• Tobacco Cessation, Cherokee

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Procedures

• Arthrocentesis Consent (WR) [PDF 315k]
• Central Line Consent (WR) [PDF 317k]
• Sterilization Consent (30 day form) [PDF 331k]

Radiology

• Contrast Intravenous Consent Form (WR) [WORD 26k]

Respiratory

• Asthma card - child care, Allergy and Asthma Foundation of America
• Pneumonia Admission Orders (PIMC) [WORD 38k]

Rheumatology

• Infliximab & Etanercept Consent (WR) [PDF 309k]

Substance Abuse

• Alcohol Withdrawal Assessment Sheets (PIMC Apr 05) [WORD 140k]

• Alcohol Withdrawal Protocol (PIMC Apr 05) [WORD 55k]

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Women's Health

• Diabetes in pregnancy checklist [WORD 53k]

• Hypertension in pregnancy checklist [WORD 49k]

PCC+ Forms for Women's Health and Prenatal Care
Please note: the Word documents are all about 160k and the PDF's are about 50k.

Colposcopy PCC+ form:	Word       PDF
Did not keep appointment (DNKA):	Word PDF
Family Planning:	Word       PDF
Gynecology:	Word       PDF
Gynecology Comprehensive:	Word PDF
Gynecology Walk-in:	Word PDF
Labor & Delivery:	Word       PDF
L / D Triage (ANMC):	Word       PDF
Midwifery:	Word       PDF
OB/GYN Call-in/Phone:	Word       PDF
OB/GYN Walk-in:	Word       PDF
OB Revisit:	Word       PDF
OB Walk-in:	Word       PDF
Postpartum:	Word       PDF
Prenatal Revisit No. 2:	Word PDF
Prenatal flow sheet, ANMC:	Word PDF
Tobacco cessation, Cherokee:	Word
Tobacco Cessation Chart form: Five A's:	PDF [18k]
Well Women's Exam:	Word

• Prenatal and Pregnancy Flowsheet - Albuquerque Service Unit: Medical Record
  • Page 1 [WORD 98k] • Page 2 [WORD 57k]
• Prenatal assessment: ETOH, substances, Domestic Violence [PDF 24k]
• VBAC and TOLAC Consent Forms
  • University of New Mexico: TOLAC consent [WORD 24k]
  • Vermont/New Hampshire VBAC Project: Consent for Birth After Cesarean [PDF]

Tubal ligation Consent (30 day form) [PDF 331k]

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Please note, regarding the material described above:

• The material presented is meant to further your local discussion of best practices. It is not meant to provide a template for care. Please share it with your local clinical staff and alter to fit your local needs
• Material for each topic on these sites has been developed by other providers based on that person's clinical judgment and experience as an expert in that field
• The material does not represent official policy or recommendations of the Indian Health Service or the other agencies involved
• Its publication should not be construed as excluding other acceptable methods of handling similar problems
• Please let the site coordinator know if you have questions or concerns about any of the material. Thanks