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Palliative patient status update form

= South West LHIN First Dose IV & Iron Sucrose in Community Screener Last Updated: 201 9-10 -21 Page 1 IV Administration Screener: First Dose IV & Iron Sucrose. To be completed & sent along with “IV Antibiotic Referral Form” or appropriate prescription Patient Name: ______________________________________________ HCN: ______________________________DOB:___________________ Address:___________________________________________________ Phone: ___________________________ Cell: ____________________ Medication […]

Enteral Feeding Form, Jan 2020

[…] TREATMENT ORDER FORM DIAGNOSIS : Type 1 Diabetes Pl anned Start Date : REASON FOR REFERRAL TO LHIN: Child/teen requires school support over the lunch hour with: in su lin administration blood glucose monitoring Tim ing: _______________________________________________________________________ Chil d/teen and family to return to Children’s Hospital for ongoing diabetes education and support. If que […]

[…] Chloride x 1 L ☐ Other hydration solution:__________________________________________________________________ Total Vo lume: _________________________ Rate: ________ mL/hr Frequency : ___________ R oute: ☐ IV ☐ Subcutaneous D uration of In– Home Treatment: __________ Days OR _____________ Doses L ist ALL Drug Allergies: _________________________________________________________________ Special Instructions:____________________________________________________________________ __________________________________________________________________________________________________ Other Hydrations available include: Potassium Chloride 20 mE q.L in […]

[…] hereby designate the person(s) and/or entity(s) set out above as my HOOPP beneficiary(s). I acknowledge that personal information on this form is being collected, used and maintained in order for HOOPP to provide pension services. I understand that personal information may be disclosed to third parties under contract with HOOPP to complete these services. […]

[…] to following expectations outlined b elow. Additionally, employees are responsible for maintaining a healthy and safe work environment by completing a Health & Safety Inspection Checklist (Referenced in the Health and Safety policy) on a monthly basis. Any areas that require attenti on, must be addressed by the Employee and reported to their Manager. […]

[…] ☐ Yes ☐ No Clinical Information Primary Diagnosis _______________________________________________________________________ PPS ____________ Secondary Diagnoses / Comorbidities _______________________________________________________________________ Prognosis ☐ Days ☐ Weeks ☐ greater than 3 months DNR in place ☐ Yes ☐ No Main Concern _____________________________________________________________________ _______________________ _________________________________________________________________________________________________________ ______________________________________________________________________________________________________ ___ Nursing Agency and key contact _ ________________________________________________________________________ ___ Attachments: ☐ Medical Summary / Health […]