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Adult Annual Health Questionnaire
- This is a PCC+ Health Questionnaire. It is recommended that patients fill one out annually, and then, prior to subsequent visits during the year, scan / review form for any changes. Providers can document changes in the ROS Update section. The template also provides an opportunity for the patient to review and update the third party insurance information on file. [DOC - 40.5K] File: ahq_template.doc Author: Schiffel, John M. - March 08, 2005. |
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Ambulatory Care PCC+ Template
- Use with mail merge header and data files. Reviewed and approved by PCC+ Implementation Team. Updated with Patient Education Information. [DOC - 214.5K]
File: ambcare_template1.doc Author: PCC+ Team - November 04, 2004. |
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Ambulatory From (captures Asthma data)
- This form was designed for use in an Ambulatory setting. This form captures Asthma data. [DOC - 215.5K]
File: ambcare_asthma_template1.doc Author: ARS Consultation Team - November 05, 2004. |
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Anticoagulation PCC+ Form
- An Anticoagulation PCC+ form developed by Chris Lamer and tested among the Pharmacy staff at the Cherokee Indian Hospital. Updated with revised Patient Education information. [DOC - 79.0K]
File: anticoag_template.doc Author: Chris Lamer - November 04, 2004. |
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Approved Pharmacy Template
- Word version of the Approved Pharmacy Template. [DOC - 141.5K]
File: FINALpharmacy_template.doc Author: PCC+ Forms Group - June 25, 2002. |
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CVD Template
- A PCC+ template designed to capture Cardiovascular Disease data. Template was reviewed by Dr. James Galloway. [DOC - 194.5K]
File: cvd_template.doc Author: Chris Lamer - January 31, 2005. |
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Diabetes Foot Exam (Annual) Template
- Use with Word mail merge header and data files. Reviewed and approved by National Diabetes Program. [DOC - 313.5K]
File: dmannualfoot_template.doc - March 14, 2002. |
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Diabetes Foot Exam (Comprehensive) Template
- Use with Word mail merge header and data files. Reviewed and approved by National Diabetes Program. [DOC - 318.5K]
File: dmcompfoot_template.doc Author: PCC+ Team - March 14, 2002. |
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Diabetes PCC+ Template
- Use with mail merge header and data files. Reviewed and approved by National Diabetes Program. [DOC - 362.5K]
File: FINALdm_template.doc Author: PCC+ Team - March 19, 2002. |
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Diabetic Education Form
- A PCC+ encounter form used to document diabetic education activities. This form was developed at Southern Colorado Ute Service Unit as part of their effort to gain recognition as an IHS Integrated Diabetes Education Program. Credit for form development should be given to Matthew Clark MD, Anne Jensen, RN, CDE, Shawna Off, RD, and John Schiffel, MT. It’s very satisfying for all of us to be able to make a contribution that will extend beyond our immediate service population. [DOC - 231.5K]
File: dmedgrid_template.doc Author: PCC+ Forms Group - November 26, 2003. |
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Elder Template
- Use with mail merge header and data files. Reviewed and approved by PCC+ forms group. [DOC - 291.5K]
File: FINALelder_template.doc Author: PCC+ Forms Group - July 08, 2002. |
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ER/Inpatient Transfer Template
- This template is meant to replace the "IHS-517 Out-Of-Hospital-Transfer Record" form. The current IHS-517 form is a carbon copy form that requires the use of a typewriter which may not always be available. [DOC - 110.0K]
File: transfer_template1.doc Author: Clarenece Smiley - April 01, 2005. |
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Inpatient Education Form
- When a patient is admitted to the ward, a visit is not created each time a member of the health care team educates a patient. Instead, a group visit form is used which records all of the education that a patient receives from all of the providers who did the education during the admission. The primary purpose of this form is not to generate a visit, but to populate the patient's information on the form and assist in the collection and documentation of patient education. ** This form was approved by Mary Wachacha, IHS Health Education Consultant. ** [DOC - 89.5K] File: inpatient_education_template.doc Author: Chris Lamer - August 26, 2005. |
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Laboratory Form
- This form has been tested for reliability, validity, and useability. Implementation of this form has also solved the common problem of "orphan labs". [DOC - 59.5K]
File: laboratory_template.doc Author: Clarenece Smiley - Vicky Jenkins - December 23, 2003. |
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Laboratory Form - Hard Coded
- This PCC+ form contains the "generic" common laboratory exams that were suggested by the "Laboratory PSG". The CPT codes have been left blank giving individual sites the opportunity to "hardcode" CPT codes onto the form. [DOC - 64.0K]
File: lab_template.doc Author: PCC+ Team - December 23, 2003. |
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Mail Merge Instructions
- READ BEFORE USING TEMPLATES. Instructions for attaching header and data files from a site's PCC+ database to a template. [PDF - 63.0K]
File: Mail_Merge_Instructions__Rev_.pdf Author: Full Circle Software - December 27, 2001. |
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MNT Diabetes Template
- The template is designed to capture the required documentation as outlined in the American Dietetic Association Medical Nutrition Therapy Protocols for Diabetes. This template was developed with input from: Sara Thomas, Cecelia Butler, Lorraine Whitehair, Graydon Yatabe, Erica Stark, Joanne Hurley, Lowell Rae Matlock, Catherine Wall, Barb Himes, Connie Hageman [DOC - 154.0K]
File: MNTdiabetes_template_.doc Author: Tammy Brown, RD - April 17, 2003. |
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MNT Kidney Template
- The template is designed to capture the required documentation as outlined in the American Dietetic Association Medical Nutrition Therapy Protocols for Chronic Kidney Disease (non-dialysis). This template was developed with input from: Tammy Brown, Sara Thomas, Cecelia Butler, Lorraine Whitehair, Graydon Yatabe, Erica Stark, Joanne Hurley, Lowell Rae Matlock, Catherine Wall, Barb Himes, Connie Hageman [DOC - 160.0K]
File: MNTKidney_template.doc Author: Theresa Kuracina, RD - April 17, 2003. |
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Nutrition Template
- Template to record Nutrition. [DOC - 147.5K]
File: nutrition_template.doc Author: Nilofer Couture - January 20, 2005. |
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Pain Management - Follow-up
- This template was developed to evaluate paid during follow-up visits. The content was reviewed by pain clinic providers and Francis Placide, PA. [DOC - 151.5K]
File: painup_template.doc Author: Francis Placide - March 09, 2005. |
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Pain Management - Initial Evaluation
- This template was developed to be used during an initial evaluation of Pain. The content was evaluated by pain clinic providers and Francis Placide, PA. [DOC - 152.0K]
File: pain_template.doc Author: Francis Placide - March 09, 2005. |
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Ped-B Template
- An updated version (h9-h50) of the Well Child form with precision content that replaces the entire set of pre-printed Well Child forms currently in use. The form includes growth grids as well as "reminder tables" for immunization forecasting, immunization history, development milestones, nutritional counseling topics, and patient education. [DOC - 1,410.5K]
File: pedb_template.doc Author: Shorr, Greg - October 14, 2004. |
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Pharmacy Brief
- A brief template used for pharmacy. [DOC - 49.0K]
File: pharmacybrief.doc Author: Pharmacy PSG - January 07, 2003. |
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Pharmacy Template
- This template allows you to capture needed data for Pharmacy visits. [DOC - 125.5K]
File: pharmacy_template.doc Author: Chris Lamer - January 21, 2005. |
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Physical Exam PCC+ Template
- Use with mail merge header and data files. Reviewd and approved by clinical specialty workgroup. [DOC - 194.5K]
File: PE_Template.doc Author: PCC+ Team - July 08, 2002. |
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Sample Header and Data Files
- Updated (8/19/04) Zip file containing SAMPLE header and data info for use to view templates. Follow Mail Merge instructions to create site specific header and data files. [ZIP - 7.3K]
File: SampleFiles.zip Author: Shorr, Greg - August 19, 2004. |
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Tobacco Template
- This PCC+ form is designed for use in the Tobacco Cessation Clinic (Clinic Code 94). [DOC - 100.5K]
File: tobacco_template.doc Author: Smiley - Lamer - Wachacha |
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Well Woman PCC+ Template
- Use with Word mail merge header and data files. Reviewed and approved by PCC+ Implementation Team. [DOC - 494.0K]
File: Women_template.doc Author: PCC+ Team - July 08, 2002. |
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Wound Care Template
- This form was developed for Wound Care clinic and is for wound care assessement, treatment, and wound care education. [DOC - 629.5K]
File: woundcare_template.doc Author: Smiley - Dorgan - August 19, 2004. |
