Hospital Forms
Sutter Medical Center, Sacramento

Number Title Category
Surgery Scheduling Database Surgery
Ventilator Protocol Worksheets
5 East CVIU Orientation Packet Worksheets
SMH - ICU - CICU Agency Orientation Packet Worksheets
SGH - ICU Agency Orientation Packet � Worksheets
SMH ED Orientation Packet Worksheets
SGH ED Orientation Packet Worksheets
4 W Oncology Orientation Packet Worksheets
5 South Float - Agency Orientation Packet 2008 Worksheets
4 South Float - Agency Orientation 2008 Worksheets
4 North Orthopedics Orientation Packet Worksheets
4 East Neurology Orientation Worksheets
3C SBAR Report Form Worksheets
Ticket for Two Worksheet Worksheets
SMH PAA Assignment Sheet Worksheets
SGH PAA Assignment Sheet Worksheets
3C Float Packet Worksheets
Patient's Guide to Blood Transfusion Worksheets
PAA Report Sheet Worksheets
PAA Activity Log Worksheets
Patient Activity Aide- Unit Evaluation Form Worksheets
Per Diem LVN- Unit Evaluation Form Worksheets
Per Diem Monitor Tech - Unit Evaluation Form Worksheets
Per Diem Nursing Assistant - Unit Evaluation Form Worksheets
Per Diem Registered Nurse - Unit Evaluation Form Worksheets
Per Diem Unit Secretary - Unit Evaluation Form Worksheets
Smoking Cessation Patient Information Patient Education
Confidential Morbidity Report Legal
SGH IV Therapy Worksheet Worksheets
SMH IV Therapy Worksheet Worksheets
00034 EKG Rhythm Strips Nursing Documentation
00035 Pediatric discharge Instructions for Cardiac Catherization
Print 2 Copies		 Discharge Instructions
00043 SCN Protocol Log Nursing Documentation
00067 Autopsy: Authorization for..
Print 2 Copies		 Consents
00075 Fetal /Neonatal Plan of Care MD Documentation, Nursing Documentation
00082 D&C / Hysteroscopy Post Op DC Instructions Discharge instructions
Print 2 Copies		 Discharge Instructions
00083 Post-Op Laparoscopy Surgery Discharge Instructions
Print 2 Copies		 Discharge Instructions
00088 Admission Physical Assessment Nursing Documentation
00148 Standard Care Statement Outpatient Surgery Nursing Documentation
00152 Death: Record of Death & Disposition Form in Central Services
00215 Continuing Education Duty Time Request Hospital
00228 ACU Post Op Phone Call Nursing Documentation
00235 Paul Gann Transfusion Information Form
Print 2 Copies		 Consents
00285 Physician Progress Notes MD Documentation
00310 SCN Patient Profile Nursing Documentation, SCN/NICU
00338 Discharge Instructions - Generic Nursing
Print 2 Copies		 Discharge Instructions
00351 Pediatric Outpatient Record Nursing Documentation
00365 Sponge, Instrument and Needle Counts - Surgery Nursing Documentation
00395 Consent for Vaccine Administration
Print 2 Copies		 Consents
00431 Refusal of Treatment, Procedure and/or Safety Device Hospital
00511 Patient Profile Inpatient Adult Nursing Documentation
00512 Pre-Ops Teaching Confirmation Nursing Documentation
00529 Communicable Disease Exposure for ED Personnel Nursing Documentation
00576 MAR - Medication Administration Record MAR's
00604 Nursery 'Special Tests Record' Worksheets
00650 Anesthesia Evaluation MD Documentation
00659 Cardiac Cath Lab Pre-Procedure Check-list Nursing Documentation
00660 Exercise Testing patient Information, CV non-invasive Lab
Print 2 Copies		 Consents
00669 MAR - Medication Administration Record for Short Term Areas MAR's
00719 Pediatric Procedure Pre-Anesthesia Checklist Nursing Documentation
00736 Authorization for Restriction on Release of Personal Health Information (No info) Hospital
00749 Discharge Instructions for Post Heart Catheterization/Angioplasty/Stent Care
Print 2 Copies		 Discharge Instructions
00787 Diabetic Record Nursing Documentation
00832 Photo Consent- Adult; Consent to Photograph, Filming, Videotaping, or use of Recording Devices
Print 2 Copies		 Consents
00842 Nursing Pharmacy Requisition Worksheets
00902 Parenteral Fluid Administration Record Nursing Documentation
00966 Consultation Record MD Documentation
01024 Patient Orientation SOMT
01052 Lost/Damaged Property Hospital
01070 Surgical Checklist Nursing Documentation
01186 L&D MD Physical Exam MD Documentation
01206 IABP- Intra-Aortic Balloon Pump Flowsheet Nursing Documentation
01246 PICC Record Nursing Documentation, Hard Copy Only
01367 - Gen AdultAdult Outpt. Home Care Inst. PACU, ACU
Print 2 Copies		 Discharge Instructions
01367 - Mem Adult OP Home Care Instructions
Print 2 Copies		 Discharge Instructions
01376 Labor & Delivery Pre-Op Surgical Checklist Nursing Documentation
01448 IV Therapy Documentation Record Nursing Documentation, Hard Copy Only
01630 ACU Post Op Patient Progress Report Nursing Documentation
01649 L&D OB Check
Print 2 Copies		 Discharge Instructions
01689 Lithotripsy Patient Treatment Record MD Documentation
01692 Autotransfusion Record Nursing Documentation
01705 Cath Lab Post Procedure HCHA Progress Record Nursing Documentation Nursing Documentation
01706 Outpatient Discharge Instructions
Print 2 Copies		 Discharge Instructions
02239 Consent for Transport to SMH
Print 2 Copies		 Consents
02266 Neurological Flowsheet Nursing Documentation
02424 Ambulatory Care Unit Pre- Op Flow Sheet Nursing Documentation
02452 Advanced Life Support Notes SCN/NICU
02452 Advanced Life Support Notes (Continuation) SCN/NICU
02657 Apheresis Unit - Hematopoietic Progenitor Cells Apheresis (HPC, Apheresis) Report of Adverse Reaction Event Nursing Documentation
02762 Seizure Log Nursing Documentation
02910 L&D Sponge, Needle and Inst. Count Nursing Documentation
02933 Fetal Movement Diary Category Worksheet Worksheets
06157 Medication Event & Near Miss Evaluation Hospital
09125 SCN Diode Laser Procedure Record Nursing Documentation
09268 Sedation Record, Patient Nursing Documentation
09269 Outpatient Instructions After Sedation
Print 2 Copies		 Discharge Instructions
09353 Social Work Consultation Psycholsocial Assessment Social Work
09422 Patient Profile, Pediatrics Nursing Documentation
09455 Outpatient Discharge Instructions Biopsies, Pacemakers, ICD's
Print 2 Copies		 Discharge Instructions
09513 Fire Event Evaluation Hospital
09545 Short Form Operative and Invasive Procedures MD Documentation
09680 Emergency Department Nursing Flow Sheet Nursing Documentation
09755 Employment and Orientation Notification Worksheet Worksheets
09977 Standard Care Statement for Patients Having Surgery Nursing Documentation
20022 PCA Intravenous Patient-Controlled Analgesia Patient Education
20129 Photo Consent, Pediatric
Print 2 Copies		 Consents
20141 Elimination Program Daily Record SOMT
20142 Informed Refusal L&D and ED
Print 2 Copies		 Consents
20143 3C Assignment Sheet and Break Log Worksheets
20207 Physician Pre-Procedural Assessment /cath lab-EP Lab MD Documentation
20252 Fall Management Conference SOMT
20262 Deep Brain Stimulation Phase 1
Print 2 Copies		 Discharge Instructions
20274 Deep Brain Stimulation Phase 2
Print 2 Copies		 Discharge Instructions
20283 Resuscitation Review Nursing Documentation
20301 Crash Cart Checklist Nursing Documentation
20385 PICC and Midline Maintenance Guide Nursing Documentation
20392 Managing Your Pain: what you need to know Patient Education
20419 Dept. Charges IV Therapy Worksheets
20433 Staffing Office Info to Fax Worksheet Worksheets
20622 Obstetric Ultrasound Exam Report MD Documentation
20650 Authorization for Use or Disclosure of Health Information
Print 2 Copies		 Consents
20675 MD Progress Notes (formatted) MD Documentation
20699 ACU Admitting Nurse Notes Nursing Documentation
20723 Pregnancy Activity Levels Antepartum Patient Guidelines Patient Education
20725 Cervical Discectomy Flowsheet Nursing Documentation
20734 Canine Companion Facility Dog Consent
Print 2 Copies		 Consents
20756 Car Seat Resources Patient Education
20777 EMU Monitor Tech Activity Sheet Worksheets
20797 5C Assignment Sheet and Break Log Worksheets
20798 PICC Alert Sign Nursing Documentation
21000 2C Assignment Sheet and Break Log Worksheets
21010 Heart Care At a Glance, Heart Failure Discharge Instructions
Print 2 Copies		 Discharge Instructions
21015 Colonoscopy Discharge Instructions
Print 2 Copies		 Discharge Instructions
21022 3C / 5C Inter-Staff Communication/ I & O's Worksheets
21027 Orthostatic Blood pressure Nursing Documentation
21069 Endoscopy Pre Procedure H&P MD Documentation
21090 Surgical Services Site/Side Documentation Nursing Documentation
21097 Addendum to Standard Care Statement Nursing Documentation
21146 Neonatal Abstinence Flow Sheet Nursing Documentation
21178 Patient Identification - Diagnostic Imaging Radiology / IR Hospital
21184 Glucophage, Patients taking
Print 2 Copies		 Discharge Instructions
21217 OrthoPAT Record Nursing Documentation
21224 Dysphagia Screening for Stroke Patients Nursing Documentation
21226 Thoracic or Lumbar Laminectomy/Disectomy Flowsheet Nursing Documentation
21227 Renal Dialysis 24-Hour Peritoneal Flowsheet Nursing Documentation
21244 Perinatal Flowsheet Nursing Documentation
21288 Consent Capsule Endoscopy
Print 2 Copies		 Consents
21293 Pediatric Op Home Care Instructions
Print 2 Copies		 Discharge Instructions
21306 Post Procedural Call Cardiac Cath / EP Lab Nursing Documentation
21308 Consent PICU/ED eHealth Consultation
Print 2 Copies		 Consents
21311 Central Venous Cath Homecare
Print 2 Copies		 Discharge Instructions
21328 Ostomy Care Documentation WOCN
21341 Stroke RN Acute Progress Note Nursing Documentation
21356 ED and L&D Transfer / Consent
Print 2 Copies		 Consents
21360 GI Endoscopy Post Procedure Call Nursing Documentation
21364 Patient Refusal to Transfer
Print 2 Copies		 Consents
21366 Sirolimus Flowsheet Worksheets
21367 Tacrolimus Flow Sheet Worksheets
21368 Cyclosporine Flow Worksheet Worksheets
21370 Dev. Delayed Addendum Stnd Care Statement Nursing Documentation
21371 SCS for Patients Having Out of Dept Procedure with Anesthesia/Sedation Nursing Documentation
21390 Pneumococcal/Influenza Immunization Protocol Nursing Documentation
21393 Pediatric Intensivists Progress Note MD Documentation
21411 Asthmas Treatment Inst. Peds Home Care
Print 2 Copies		 Discharge Instructions
21414 Pyxis User Request Hospital
21415 2C Interstaff Communication Worksheet Worksheets
21422 Consent Cardiac Cath Coronary Intervention - Use for non-Sacramento Heart and Vascular Cardiologists
Print 2 Copies		 Consents
21423 Consent Cardiac Cath Coronary /Peripheral Intervention - Use for Sacramento Heart and Vascular Cardiologists
Print 2 Copies		 Consents
21424 Pacemaker Homecare Inst. Sacramento - Heart and Vascular Med Association
Print 2 Copies		 Discharge Instructions
21425 Pacemaker/ ICD Homecare Inst. Sobkowicz/Berte
Print 2 Copies		 Discharge Instructions
21426 Core Measures Tool Worksheets
21427 Pacemaker / ICD Homecare Inst. Wolf
Print 2 Copies		 Discharge Instructions
21428 Mental Health Evaluation Tool MSW Documentation
21429 ATU Photograph Consent
Print 2 Copies		 Consents
21431 Monitor Tech Patient Report Worksheets
21434 ED Lab Results Letter Worksheets
21439 Temporary Absense/Transfer Release
Print 2 Copies		 Consents
21454 Pacemaker/ICD Homecare Instructions- Dr Kim
Print 2 Copies		 Discharge Instructions
21478 HRM Report: Antepartum Worksheets
21479 HRM Report: Postpartum Worksheets
21510 Pressure Ulcer Program Patient Information Patient Education
21525 Pediatric Asthma PCP Notification, ED MD Documentation
21527 Tobacco Cessation Follow-Up
Print 2 Copies		 Consents
21531 SMCS Admission Orders - Dr Morkoc Nursing Documentation
21536 Dialysis Outpatient Initial Patient Education Nursing Documentation
21539 Transport Flowsheet (SCN) Nursing Documentation
21583 Outpatient Medication Reconciliation Form Nursing Documentation
21592 OB Recovery Nursing Record Continuation Nursing Documentation
21593 VAD Heartmate XVE Flowsheet Nursing Documentation
21602 Social Work Progress Note Social Work
21609 VAD Abiomed Flowsheet Nursing Documentation
21618 Ticket to Ride Worksheet Worksheets
21624 Diagnostic Test MRI Diagnostic Imaging Documentation
21633 SMCS - Surgery Letter Patient Education
21634 ICD Discharge Instructions - Dr. Stark
Print 2 Copies		 Discharge Instructions
21640 Discharge Instructions for Care at Home - Adults
Print 2 Copies		 Discharge Instructions
21642 Pacemaker / ICD Homecare Inst.- Generic
Print 2 Copies		 Discharge Instructions
21655 VAD CentriMag Flowsheet Nursing Documentation
21672 MAR - Insulin Regular - Mild MAR's
21673 MAR - Insulin Regular - Moderate MAR's
21674 MAR - Insulin Regular - Aggressive MAR's
21675 MAR - Insulin Lispro - Mild MAR's
21676 MAR - Insulin Lispro - Moderate MAR's
21677 MAR - Insulin Lispro - Aggressive MAR's
21681 Physician Predischarge Assessment of Risk for Hyperbilirubinemia in Infant 35 Weeks Gestation (or greater) MD Documentation
21688 Inactivated Influenza Immunization, Pediatric: Protocol, Info Sheet, Consent
Print 2 Copies		 Consents
21693 ROP Follow-up SCN/NICU
21696 Daily Progress for CV Surgery Patient Education
21698 Consent for Pediatric Inactivated Influenza Vaccine Administration (Inpatient)
Print 2 Copies		 Consents
21710 Blood and Marrow Transplantation Program Summary of Records Worksheets
21711 Blood and Marrow Transplantation Program Final Donor Suitability/Eligibility Determination Worksheets
21719 Teaching Checklist - Stroke Patient Education
21723 MAR - Bowel Care - Renal MAR's
21724 MAR - Bowel Care - Routine MAR's
21725 MAR - Potassium and Magnesium Replacement Protocol MAR's
21726 MAR - Heart Failure Admission Orders 09912 MAR's
21727 MAR - Pneumonia Order Set, Adult ZZ00167 MAR's
21728 MAR - Adult Admission Orders (Non-Surgical) 21324 MAR's
21729 MAR - Chest Pain - Rule out Acute Coronary Syndrome 20663 MAR's
21732 Pre Operative Work Sheet Worksheets
21739 Advanced Directives Intensity of Care SOMT
21740 Bladder Retraining Assessment SOMT
21741 Monthly Meal Intake Record SOMT
21742 Pressure Ulcer Clinical Summary SOMT
21743 Psychotropic Medication Summary Sheet SOMT
21744 Sepsis Screen SOMT
21745 Quarterly Smokers Assessment SOMT
21748 VAD Heartmate II Flowsheet Nursing Documentation
21750 RRT Record Nursing Documentation
21754 Pediatric RRT Record Nursing Documentation
21755 Pediatric RRT Interaction Satisfaction Survey Nursing Documentation
21760 SOMT Readmit/Change in Condition Status SOMT
21761 Interdisciplinary Resident Care conference SOMT
21781 VAD Impella Flowsheet Nursing Documentation
691127 Restraint Directive SOMT