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= 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 […]

[…] Normal or reduced Full or Confusion ñ09 Mainly Sit/Lie hnable to do any
Áork Extensive disease Considerable assistance re
‹uired Normal or reduced Full or Confusion ð09 Mainly in Bed hnable to do most activity Extensive disease Mainly assistance Normal or reduced Full or Dro
Ásy =/ – Confusion 309 Totally Bed Bound hnable to do […]