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Clinical Care Forms



Chapter 1 : Clinical Forms

Section 1 : Clinical Forms

000305 : EMERGENCY INTERFACILITY PATIENT TRANSFER FORM

000306 : PATIENTS LEAVING AGAINST MEDICAL ADVICE

000921 : BEHAVIOR MANAGEMENT FLOW SHEET

010527 : DEPARTMENT OF PSYCHIATRY - WAIVER FORM

011226 : Dental Hygiene Peridontal Charting Form

011230 : PEDIATRIC - SEDATIVE / ANALGESIC WITHDRAWAL SCORING SHEET

020601 : PEDIATRIC VACCINE SCHEDULE

020602 : ADULT SKIN TEST WITH FOODS

020603 : ADULT SKIN TEST WITH ALLERGENS

020604 : ADULT STINGING INSECT VENOM SKIN TEST

020605 : PEDIATRIC SKIN TEST

020608 : ADULT VACCINE SCHEDULE

030105 : AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

030272 : REQUEST FOR AMENDMENT OF HEALTH INFORMATION

030363 : REQUEST FOR AN ACCOUNTING OF DISCLOSURES

030463 : HIPAA NOTICE OF PRIVACY PRACTICES

030463s : HIPAA NOTICE OF PRIVACY PRACTICES (SPANISH)

030663 : DIVISION OF GYNECOLOGIC ONCOLOGY - TELEPHONE CONSULT

031031 : HIM-S DOCUMENTATION REQUEST

031350 : REQUEST FOR RESTRICTION ON USES & DISCLOSURES OF HEALTH INFORMATION

33103 : CONSULTATION/DISPOSITION FOLLOWING FETAL/NEONATAL DEATH

33128 : RHYTHM STRIP FLOWSHEET

33130 : SURGICAL IMPLANT RECORD

33516 : INSURANCE WAIVER & STATEMENT OF RESPONSIBILITY FORM

33516s : INSURANCE WAIVER & STATEMENT OF RESPONSIBILITY FORM (SPANISH)

33603 : AUTHORIZATION FOR SEXUAL ASSAULT EXAMINATION

33603A : SEXUAL ASSAULT NURSE EXAMINER TEAR SART REPORT ADDENDUM

050106 : DISCHARGE TO FACILITY PACKET

050661 : RADIATION SAFETY INSTRUCTIONS FOR PATIENTS RELEASED CONTAINING GREATER THAN 6.9 mCi OF Na131 IODINE

060502 : DEPARTMENT OF DENTISTRY- WHAT TO DO AFTER PERIODONTAL SURGERY

060505 : DEPARTMENT OF DENTISTRY-WHAT TO DO AFTER DENTAL SURGERY TO CORRECT A SINUS EXPOSURE

060506 : DEPARTMENT OF DENTISTRY-WHAT TO DO AFTER YOUR CHILD’S DENTAL TREATMENT

060901 : DEPARTMENT OF RADIOLOGY — ADULT STANDARDIZED DISCHARGE FORM

060960 : OUTSIDE FACILITY NOTE

070765 : TRANSFUSION MEDICINE SERVICES — PREADMISSION ASSESSMENT SPECIMEN (PAS) PROTOCOL

080963 : Endoscopy/Bronchoscopy Supplemental Flowsheet

090368 : SHARED MEDICAL APPOINTMENT AUTHORIZATION

090962 : RENAL SERVICES – OUTPATIENT DIALYSIS

100367 : REQUEST FOR NON-DISCLOSURE OF HEALTH INFORMATION TO HEALTH PLAN

100563 : PATIENT CHOICE NOTIFICATION FORM – DURABLE MEDICAL EQUIPMENT

100766 : AMBULATORY CONTROLLED SUBSTANCE AND MEDICATION MANAGEMENT CONTRACT

100963 : FAMILY HISTORY / GENETIC PEDIGREE

110162 : THE CHILD UNDER 18 YEARS OLD: PARENT OR LEGAL GUARDIAN ACCESS TO MYCHART PROXY AUTHORIZATION FORM

110162S : PARENT/LEGAL GUARDIAN PROXY ACCESS TO MYCHART (Spanish)

110163 : ADULT PROXY ACCESS TO MYCHART BY ANOTHER ADULT

110164 : ADULT PROXY ACCESS TO MYCHART FOR “CAREGIVERS”

110165 : NEONATAL DELIVERY RECORD

110173 : Department of Orthopaedic Surgery Orthotic Soft Good Proof of Delivery

111264 : DESIGNATED HEALTH CARE AGENT*

120475 : REVOKING AN ADVANCE DIRECTIVE ON FILE AT UVA HEALTH SYSTEM

121161 : FIELD CLINIC - COMMUNICATION TO PATIENT

130270 : MOHS MAP IMAGE

130273 : PAIRED DONOR EXCHANGE PROGRAM – PARTICIPATION FORM

130274 : POTENTIAL KIDNEY, PANCREAS, & KIDNEY/PANCREAS RECIPIENT - Agreement of Understanding

130275 : POTENTIAL PEDIATRIC KIDNEY RECIPIENT - Agreement of Understanding

130276 : POTENTIAL LIVER RECIPIENT - Agreement of Understanding

130277 : POTENTIAL LUNG RECIPIENT - Agreement of Understanding

130278 : POTENTIAL HEART RECIPIENT - Agreement of Understanding

130279 : POTENTIAL LIVER TRANSPLANT RECIPIENT - SUBSTANCE ABUSE AGREEMENT

130281 : UNIVERSITY OF VIRGINIA TRANSPLANT CENTER TUBERCULIN TEST

130282 : TRANSPLANT IN - HOME SAFETY ASSESSMENT

130283 : TRANSPLANT NEUROPSYCHOLOGY –COGNITIVE MODIFICATION PATIENT EDUCATION ASSESSMENT

130284 : KIDNEY/PANCREAS TRANSPLANT PROGRAM - POTENTIAL RECIPIENT LISTING FORM

130285 : LIVER TRANSPLANT PROGRAM - POTENTIAL RECIPIENT LISTING FORM

130286 : LUNG TRANSPLANT PROGRAM - POTENTIAL RECIPIENT LISTING FORM

130287 : HEART TRANSPLANT PROGRAM - POTENTIAL RECIPIENT LISTING FORM

130288 : LIVING DONOR PROGRAM - POTENTIAL KIDNEY DONOR LISTING FORM

130289 : LIVING DONOR PROGRAM - POTENTIAL LIVER DONOR SELECTION FORM

130290 : PEDIATRIC HEART TRANSPLANT PROGRAM - POTENTIAL RECIPIENT LISTING FORM

130363 : HEPATITIS C TREATMENT ACKNOWLEDGEMENT

130460 : AMBULANCE SIGNATURE FORM

131062 : OUTSIDE FACILITY Prosthetics and Orthotics PRESCRIPTION

140161 : IT Greer (Acct # 16918 - 0000715706)

140162 : IT GREER (Acct # 16916 - 1491389)

140264 : PHYSICIAN CERTIFICATION STATEMENT FOR AMBULANCE TRANSPORTATION

140265 : NOTICE AND ASSIGNMENT OF BENEFITS AUTOMOBILE/MOTOR VEHICLE ACCIDENT PATIENTS

140266 : PHYSICIAN’S WRITTEN DIRECTIVE FOR IODINE-125 TEMPORARY IMPLANT

140268 : DIALYSIS PROGRAM - PATIENT RIGHTS AND RESPONSIBILITIES ACKNOWLEDGEMENT V10.16

140360 : ACO DECLINING TO SHARE PERSONAL HEALTH INFORMATION

140362 : EQUIPMENT WARRANTY INFORMATION FORM

140561 : TCV PERFUSION - PERFUSION CHECKLIST

140562 : TCV PERFUSION - ADULT PERFUSION RECORD

140960 : AUTHORIZATION FOR ACCESS BY HOSPITAL EDUCATION

141064 : TCV PERFUSION - CELL SAVER PROCEDURE LOG

150261 : NCCN DISTRESS THERMOMETER

151062 : VAD PATIENT EQUIPMENT RECORD

160260 : BEWELL EXAM

160360 : POTENTIAL PEDIATRIC LIVER RECIPIENT- AGREEMENT OF UNDERSTANDING

160760 : POTENTIAL PEDIATRIC HEART RECIPIENT - Agreement of Understanding

160901 : POTENTIAL DOMINO DONOR - AGREEMENT OF UNDERSTANDING

161201 Standard : VIRGINIA ADVANCE DIRECTIVE FOR HEALTHCARE STANDARD FORM

161201S : Virginia Advance Directive For Health Care Standard Form (English Version with Spanish Information)

161202 Long : LONG FORM VIRGINIA ADVANCE DIRECTIVE FOR HEALTHCARE

170301 : UVA EPILEPSY MONITORING UNIT (EMU) ADMISSION/PRECERTIFICATION REQUEST

170601 : AUTHORIZATION FOR FORENSIC SERVICES

170602 : CHILD ABUSE OR NEGLECT EXAMINATION

170603 : ADULT ABUSE OR NEGLECT EXAMINATION

170604 : STRANGULATION EXAMINATION

170605 : SEXUAL ASSAULT - PERPETRATOR EXAMINATION

170606 : MALE SEXUAL ASSAULT EXAMINATION

170607 : DOMESTIC VIOLENCE (PHYSICAL) EXAMINATION

170608 : ADULT/ADOLESCENT SEXUAL ASSAULT EXAMINATION

170801 : ALTERNATE SITE MARKING FORM

171101 : AGENT ONLY ADVANCE DIRECTIVE FOR HEALTH CARE APPOINTMENT OF AN AGENT ONLY

171201 : AUTHORIZATION FOR SHARING OF INFORMATION: PATIENT TO PATIENT

180202 : PHOTOGRAPH/IMAGE

180301 : REVOCATION OF AMBULATORY CONTROLLED SUBSTANCE & MEDICATION MANAGEMENT CONTRACT

180601 : ASPIRATION RISK SCREENING TOOL

180802 : PATIENT COMPANION COMMUNICATION TOOL- SUICIDE PRECAUTIONS

CMS-R-131-G_ABN : ADVANCE BENEFICIARY NOTICE OF NONCOVERAGE (ABN English)

010403 : Digestive Health Center of Excellence-Procedure Record

021092 : Patient Care Services-DHC Physician Pre-General Anesthesia Assessment

33025A : Blood Transfusion Consent

33621 : Physician Record Medical Command

110174 : Prosthetics and Orthotics Diabetic Physician Statement of Certifying Physician for Therapeutic Shoes

110176 : Department of Orhopaedic Surgery Custom Orthotics Proof of Delivery

190102 : Thyroid Gland Tracing

190103 : Consent for Treatment with Immune Effector Cell Therapy

190201 : Blood Administration NOT Documented in Epic

191001 : Op Note Diagram

Chapter 2 : Consents

Section 1 : Consents

000303 : CONSENT FOR AUTOPSY

000318 : CONSENT FOR DIAGNOSTIC CARDIAC CATHETERIZATION AND POSSIBLECORONARY INTERVENTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

000331 : CONSENT FOR ADULT BONE MARROW PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

000418 : AUTHORIZATION FOR RELEASE OF BIRTH ANNOUNCEMENT INFORMATION TO THE NEWSPAPERS

000505 : PATIENT ACKNOWLEDGEMENT OF RESPONSIBILITYFOR USE OF NON-UVA DEVICES (WAIVER)

010121 : CONSENT FOR DENTAL SURGERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

010122 : CONSENT FOR INTRAVENOUS SEDATION / ANALGESIA

010707 : DEPARTMENT OF RADIOLOGY – CONSENT FOR LUNG BIOPSY

010708 : DEPARTMENT OF RADIOLOGY – CONSENT FOR LIVER BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

010709 : DEPARTMENT OF RADIOLOGY – CONSENT FOR PARACENTESIS

010710 : DEPARTMENT OF RADIOLOGY – CONSENT FOR THORACENTESISAND ADMINISTRATION OF ANESTHESIA OR SEDATION

010711 : DEPARTMENT OF ORTHODONICS - CONSENT FOR ORTHODONTIC TREATMENT

011120 : DEPARTMENT OF DENTISTRY - CONSENT FOR ORAL APPLIANCE FOR SNORING AND / OR OBSTRUCTIVE SLEEP APNEA

020102 : CONSENT FOR PHOTODERM® VASCULIGHTTM TREATMENT

020410 : CONSENT FOR COURSE OF ELECTROCONVULSIVE THERAPY (ECT) AND ADMINISTRATION OF ANESTHESIA

020411 : CONSENT FOR MAINTENANCE ELECTROCONVULSIVE

020423 : SLEEP DISORDERS CENTER - CONSENT FOR VIDEO

020528 : PATIENT ACKNOWLEDGEMENT OF RESPONSIBILITY FOR USE OF NON-UVA MEDICATIONS

020931 : CONSENT FOR MEDIAL BRANCH NERVE BLOCK PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

020932 : CONSENT FOR MAJOR JOINT INJECTION PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

020933 : CONSENT FOR DENERVATION PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

020934 : CONSENT FOR PERIPHERAL NERVE BLOCK AND ADMINISTRATION OF ANESTHESIA OR SEDATION

020936 : CONSENT FOR PERIPHERAL LOCAL ANESTHETIC AND/OR ADMINISTRATION OF ANESTHESIA OR SEDATION

020937 : CONSENT FOR STELLATE GANGLION BLOCK SERIES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

020938 : CONSENT FOR EPIDURAL STEROID INJECTION PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021002 : CONSENT FOR CANDELA V-BEAM LASER TREATMENT

021003 : CONSENT FOR THYROID BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021004 : CONSENT FOR INTRAABDOMINAL FLUID COLLECTION OR ABSCESS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021012 : CONSENT FOR ADMINISTRATION OF CHEMOTHERAPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021094 : DIGESTIVE HEALTH CENTER – CONSENT FOR FLEXIBLE SIGMOIDOSCOPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021095 : CONSENT FOR UPPER ENDOSCOPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021096 : DIGESTIVE HEALTH CENTER – CONSENT FOR COLONOSCOPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

021097 : DIGESTIVE HEALTH CENTER – CONSENT FOR LIVER BIOPSY

021098 : CONSENT FOR BRONCHOSCOPY

021099 : CONSENT FOR CAPSULE ENTEROSCOPY

030112 : CONSENT FOR AORTIC ARCH AND SUBCLAVIAN ANGIOGRAM

030113 : CONSENT FOR ABDOMINAL AND/OR RENAL ANGIOGRAPHY WITH POSSIBLE INTERVENTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030381 : CONSENT FOR PUNCH BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030382 : CONSENT FOR EXCISION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030383 : CONSENT FOR SHAVE BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030384 : CONSENT FOR ELECTRODESSICATION AND CURETTAGEAND ADMINISTRATION OF ANESTHESIA OR SEDATION

030385 : CONSENT FOR SCLEROTHERAPY (LEG VEIN INJECTIONS) ANDADMINISTRATION OF ANESTHESIA OR SEDATION

030414 : CONSENT FOR PERCUTANEOUS CORONARY INTERVENTIONAND ADMINISTRATION OF ANESTHESIA OR SEDATION

030531 : CONSENT FOR EXTRACORPOREAL LIFE SUPPORT (ECLS)AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030664 : CONSENT TO PHOTOGRAPH AND/OR VIDEO

030864 : CONSENT FOR HYPERBARIC OXYGEN THERAPY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

030967 : CONSENT FOR PARATHYROIDECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030968 : CONSENT FOR TREATMENT OF THYROID MASS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030970 : CONSENT FOR TRANSVAGINAL COLPOCLEISIS OR COLPECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

030971 : CONSENT FOR TRANSVAGINAL RECONSTRUCTION

031060 : CONSENT FOR PERCUTANEOUS VERTEBROPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031061 : CONSENT FOR CEREBRAL ANGIOGRAPHY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031084 : THE HEART CENTER—CARDIOVASCULAR REHAB AND WELLNESS INFORMED CONSENT

031162 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH COIL EMBOLIZATION WITH OR WITHOUT STENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031163 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH COIL EMBOLIZATION OF AN-ANEURYSM

031164 : CONSENT FOR SPINAL ANGIOGRAPHY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031165 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH EMBOLIZATION FOREPISTAXIS/BLEEDING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031166 : CONSENT FOR SPINAL ANGIOGRAPHY WITH POSSIBLE EMBOLIZATION OF TUMOR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031167 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH AVM/AVF EMBOLIZATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031168 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH TUMOR EMBOLIZATION WITH OR WITHOUT VASCULAR CLOSURE DEVICEAND ADMINISTRATION OF ANESTHESIA OR SEDATION

031182 : CONSENT FOR CISTERNOGRAPHY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031183 : CONSENT FOR LUMBAR PUNCTURE UNDER FLUOROSCOPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031184 : CONSENT FOR MYELOGRAPHY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031185 : CONSENT FOR LUMBAR PUNCTURE UNDER FLUOROSCOPY AND INTRATHECAL CHEMOTHERAPY INJECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031194 : CONSENT FOR AV JUNCTIONAL ABLATION WITH PACEMAKER INSERTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031195 : CONSENT FOR UPRIGHT TILT TABLE TEST WITH CONTINUOUS BLOOD PRESSURE MONITORING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031196 : CONSENT FOR PERMANENT PACEMAKER INSERTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031197 : CONSENT FOR ELECTROPHYSIOLOGIC (EP) STUDY WITH POSSIBLECATHETER ABLATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031198 : CONSENT FOR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031199 : CONSENT FOR ELECTROPHYSIOLOGIC (EP) STUDY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031240 : CONSENT FOR ELECTRICAL CARDIOVERSION

031266 : CONSENT FOR RADIOSEED LOCALIZATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031267 : CONSENT FOR GALACTOGRAM ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031268 : CONSENT FOR CYST ASPIRATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031269 : CONSENT FOR CORE NEEDLE BIOPSY – BREAST MASSAND ADMINISTRATION OF ANESTHESIA OR SEDATION

031270 : CONSENT FOR CORE NEEDLE BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031273 : CONSENT FOR COLLAGEN OR FACIAL FILLER INJECTION

031275 : CONSENT FOR LIGHTSHEER LASER HAIR REMOVAL AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031276 : CONSENT FOR VERSAPULSE LASER TREATMENT ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031280 : CONSENT FOR RADIOSEED LOCALIZATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031301 : CONSENT FOR STERILIZATION ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031302 : CONSENT FOR REPAIR OF TETRALOGY OF FALLOT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031304 : CONSENT FOR ARTERIAL SWITCH OPERATION ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031305 : CONSENT FOR AORTO-FEMORAL BYPASS ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031306 : CONSENT FOR SURGICAL REVASCULARIZATION ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031307 : CONSENT FOR LUNG RESECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031308 : CONSENT FOR CAROTID ENDARTERECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031309 : CONSENT FOR VALVE REPLACEMENT OR REPAIR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031310 : CONSENT FOR CORONARY ARTERY BYPASS GRAFTING ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031311 : CONSENT FOR REPAIR OF ABDOMINAL AORTIC ANEURYSM ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031312 : CONSENT FOR ESOPHAGECTOMY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031315 : CONSENT FOR CLOSURE OF VENTRICULAR SEPTAL DEFECTAND ADMINISTRATION OF ANESTHESIA OR SEDATION

031316 : CONSENT FOR CLOSURE OF PATENT DUCTUS ARTERIOSUSARTERIOSUS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

031317 : CONSENT FOR REPAIR OF ATRIAL SEPTAL DEFECT ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031318 : CONSENT FOR REPAIR OF COARCTATION OF AORTA ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031319 : CONSENT FOR THORACENTESIS ANDADMINISTRATION OF ANESTHESIA OR SEDATION

031320 : INPATIENT PSYCHIATRIC UNITS INFORMATION DISCLOSURE CONSENT

33025 : CONSENT FOR MEDICAL/SURGICAL PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

033376 : EMERGENCY DEPARTMENT RECORD – CONSENT TO TREAT

040162 : CONSENT FOR CIRCUMCISION OF PENIS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040164 : CONSENT FOR CESAREAN DELIVERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040360 : CONSENT FOR CERVICAL DILATATION AND SUCTION CURETTAGE FOR ELECTIVEABORTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040369 : CONSENT FOR TRANSURETHRAL RESECTION OF THE PROSTATEAND ADMINISTRATION OF ANESTHESIA OR SEDATION

040370 : CONSENT FOR PUBOVAGINAL SLING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040371 : CONSENT FOR EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

040373 : CONSENT FOR TRANSPERINEAL IMPLANT OF RADIOACTIVE SEEDSAND ADMINISTRATION OF ANESTHESIA OR SEDATION

040375 : CONSENT FOR PERIURETHRAL COLLAGEN INJECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040376 : CONSENT FOR CRYOABLATION OF PROSTATE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040377 : CONSENT FOR RADICAL CYSTECTOMY WITH URINARY DIVERSION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040378 : CONSENT FOR CYSTOSCOPY, POSSIBLE BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040379 : CONSENT FOR ORCHIECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040380 : CONSENT FOR PERCUTANEOUS LITHOTRIPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040381 : CONSENT FOR PYELOPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040382 : CONSENT FOR RADICAL NEPRECTOMY

040383 : CONSENT FOR RETROPUBIC PROSTATECTOMY WITH PELVIC LYMPH NODE DISSECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040384 : CONSENT FOR TRANSURETHRAL RESECTION OF BLADDER TUMOR

040385 : CONSENT FOR URETERAL REIMPLANT

040386 : CONSENT FOR CYSTOSCOPY WITH URETERAL STENT CHANGE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040387 : CONSENT FOR OUTPATIENT DILATATION AND CURETTAGE ANDADMINISTRATION OF ANESTHESIA OR SEDATION

040393 : CONSENT FOR VASECTOMY

040394 : CONSENT FOR VARICOCELECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040395 : CONSENT FOR ADRENALECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040682 : CONSENT FOR STRESS URINARY INCONTINENCE PROCEDURES ANDADMINISTRATION OF ANESTHESIA OR SEDATION

040683 : CONSENT FOR PELVIC ORGAN PROLAPSE PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040861 : CONSENT FOR SEPTOPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040862 : CONSENT FOR FUNCTIONAL ENDOSCOPIC SINUS SURGERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

040863 : CONSENT FOR CEREBRAL ANGIOGRAPHY AND ANGIOPLASTY WITH OR WITHOUT STENT ADMINISTRATION OF ANESTHESIA OR SEDATION

041060 : PEDIATRIC CARDIOLOGY – CONSENT FOR PERMANENT PACEMAKERINSERTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041061 : PEDIATRIC CARDIOLOGY CONSENT FOR ELECTROPYSIOLOGIC (EP) STUDY WITH POSSIBLE CATHETER ABLATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041062 : DEPARTMENT OF PEDIATRIC CARDIOLOGY CONSENT FOR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR INSERTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041063 : DEPARTMENT OF PEDIATRIC CARDIOLOGY CONSENT FOR ELECTROPHYSIOLOGIC STUDY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041166 : CONSENT FOR MINOR OFFICE PROCEDURES IN ORTHOPAEDICS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041171 : CONSENT FOR RADIOACTIVE IODINE-131 THERAPY FOR THYROTOXICOSIS

041172 : CONSENT FOR ADMINISTRATION OF RADIOACTIVE SAMARIUM-153

041173 : CONSENT FOR ADMINISTRATION OF RADIOACTIVE YTTRIUM-90 ZEVALIN

041174 : CONSENT FOR ADMINISTRATION OF RADIOACTIVE IODINE-131 THERAPY FORTHYROID CANCER AND ADMINISTRATION OF ANESTHESIA OR SEDATION

041269 : CONSENT FOR TRANSESOPHAGEAL ECHOCARDIOGRAM/ULTRASOUND IMAGING OF THE HEART

041402 : CONSENT FOR BURN/WOUND CARE AND DRESSING CHANGES

050160 : CONSENT FOR PERMANENT PACEMAKER GENERATOR CHANGE ANDADMINISTRATION OF ANESTHESIA OR SEDATION

050161 : CONSENT FOR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR GENERATORCHANGE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050166 : CONSENT FOR VASODILATOR STRESS TEST

050167 : CONSENT FOR DOBUTAMINE STRESS TEST

050169 : CONSENT FOR EXERCISE STRESS TEST

050278 : CONSENT FOR LAPAROSCOPIC ROBOTIC-ASSISTED PROSTATECTOMY

050360 : DIGESTIVE HEALTH CENTER – CONSENT FOR ERCP, ADMINISTRATION OF ANESTHESIA OR SEDATION AND PHOTOFRIN (PROFIRMER SODIUM) ADMINISTRATION WITH PHOTODYNAMIC LASER TREATMENT

050362 : DIGESTIVE HEALTH CENTER – CONSENT FOR UPPER ENDOSCOPY,

050379 : CONSENT FOR AMPUTATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050569 : CONSENT FOR ABDOMINAL ARTERIOGRAM AND LOWER EXTREMITY

050570 : CONSENT FOR CARDIAC CATHETERIZATION AND ALCOHOL SEPTAL ABLATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050763 : CONSENT FOR NEWBORN TRANSPORTATION AND TREATMENT BY THE NEWBORN EMERGENCY TRANSPORT SYSTEM (NETS)

050772 : CONSENT FOR SCATTER/FOCAL LASER PHOTOCOAGULATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050862 : CONSENT FOR EXAM UNDER ANESTHESIA AND TRABECULOTOMY

050863 : CONSENT FOR BLEB REVISION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050864 : CONSENT FOR TREATMENT OF CHOROIDAL DETACHMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050865 : CONSENT FOR CATARACT EXTRACTION AND GLAUCOMA DRAINAGE TUBE IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050866 : CONSENT FOR GLAUCOMA DRAINAGE TUBE IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050867 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050868 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND TRABECULECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050869 : CONSENT FOR TRABECULECTOMY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

050960 : CONSENT FOR OBSTETRIC PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050971 : CONSENT FOR LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP) AND ADMINISTRATION OF ANESTHESIA OR SEDATION

050973 : CONSENT TO RADIATION THERAPY

060562 : CONSENT FOR MOHS MICROGRAPHIC SURGERY, SURGICALREPAIR OF THE RESULTING WOUND AS DEEMED APPROPRIATE,AND ADMINISTRATION OF ANESTHESIA OR SEDATION

060567 : CONSENT TO PARTICIPATE IN TELEMEDICINE CONSULTATION

060965 : CONSENT FOR FETAL BLOOD SAMPLING/TRANSFUSION

060966 : CONSENT FOR DIAGNOSTIC AMNIOCENTESIS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

060967 : CONSENT FOR CHORIONIC VILLUS SAMPLING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070160 : DEPARTMENT OF RADIOLOGY – CONSENT FOR BALLOON DILATION DEPARTMENT OF RADIOLOGY – CONSENT FOR BALLOON DILATION

070477 : CONSENT FOR ADMINISTRATION OF GADOLINIUM BASED MRI CONTRAST AGENT

070763 : CONSENT FOR PLACEMENT OF INTRAUTERINE DEVICE (IUD)

070861 : CERTIFICATION OF ADULT PATIENT CAPACITY TO CONSENT TO TREATMENT

070868 : CONSENT FOR TREATMENT OF VENTRICULAR ARRHYTHMIAS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070870 : CONSENT FOR CENTRAL LINE CHECK AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070871 : CONSENT FOR CENTRAL LINE PLACEMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070872 : CONSENT FOR UPPER EXTREMITY VENOGRAM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070873 : CONSENT FOR LOWER EXTREMITY VENOGRAM

070874 : CONSENT FOR PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070875 : CONSENT FOR BILIARY TUBE CHECK AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070876 : CONSENT FOR PULMONARY ARTERIOGRAM

070877 : CONSENT FOR NEPHROSTOMY TUBE CHECK AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070878 : CONSENT FOR UPPER EXTREMITY THORACIC AORTAGRAM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070879 : CONSENT FOR TUNNELED LINE PLACEMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070880 : CONSENT FOR FISTULAGRAM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070881 : CONSENT FOR RENAL ANGIOGRAM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070882 : CONSENT FOR ABDOMINAL AORTOGRAM ANDADMINISTRATION OF ANESTHESIA OR SEDATION

070883 : CONSENT FOR AORTOGRAM WITH RUNOFF AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070884 : CONSENT FOR NEPHROSTOMY TUBE PLACEMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070885 : CONSENT FOR TRANSJUGULAR PORTO-SYSTEMIC SHUNT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070886 : CONSENT FOR IVC FILTER PLACEMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070887 : CONSENT FOR TREATMENT OF GI BLEEDING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070888 : CONSENT FOR TREATMENT OF MESENTERIC ISCHEMIA AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070889 : CONSENT FOR TRANSJUGULAR LIVER BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070890 : CONSENT FOR UTERINE FIBROID EMBOLIZATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070891 : CONSENT FOR EMBOLIZATION OF LIVER TUMOR WITH CHEMOTHERAPY ANDADMINISTRATION OF ANESTHESIA OR SEDATION

070892 : CONSENT FOR RADIOFREQUENCY ABLATION OF LIVER TUMOR

070893 : CONSENT FOR ENDOVASCULAR STENT GRAFT REPAIR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070894 : CONSENT FOR INFERIOR PETROSAL SINUS SAMPLING AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070895 : CONSENT FOR PORT PLACEMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070896 : CONSENT FOR PERCUTANEOUS THROMBOLYSIS OF VEINS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070897 : CONSENT FOR IVC/SVC FILTER REMOVAL

070898 : CONSENT FOR EMBOLIZATION OF VASCULAR MALFORMATION WITH ALCOHOL

070899 : CONSENT FOR PERCUTANEOUS VARICOSE VEIN ABLATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

070960 : CONSENT FOR SCLEROTHERAPY OF VEINS

070961 : CONSENT FOR RADIOFREQUENCY ABLATION OF LUNG MASS

070962 : CONSENT FOR REMOVAL OF PORT OR TUNNELLED VENOUS ACCESS

070963 : CONSENT FOR EMBOLIZATION OF VESSELS TO A TARGET ORGAN

071262 : CONSENT FOR RECIPIENTS OF LIVERS FROM HCV POSITIVE DONORS

071263 : CONSENT FOR CATARACT EXTRACTION, LENS IMPLANT AND CORNEAL

071264 : CONSENT FOR PK/IOL EXCHANGE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071265 : CONSENT FOR CORNEAL TRANSPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071266 : CONSENT FOR TREATMENT OF KERATOCONUS

071267 : CONSENT FOR TREATMENT OF CORNEAL EDEMA AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071268 : CONSENT FOR EXCISION OF TUMOR AND CRYOTHERAPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071269 : CONSENT FOR DEBRIDEMENT OF CORNEA AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071270 : CONSENT FOR EXCISION OF PTERYGIUM AND CONJUNCTIVAL GRAFT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071271 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

071272 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND TRABECULECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

080161 : CONSENT FOR OPEN REPAIR OF DESCENDING THORACIC AORTIC ANEURYSM DISSESCTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

080365 : CONSENT FOR EP STUDY WITH POSSIBLE ENDOCARDIAL OR EPICARDIAL

080461 : CONSENT FOR PHOTODYNAMIC THERAPY

080462 : CONSENT FOR PSORALEN ULTRAVIOLET A (PUVA) TREATMENT

080483 : CONSENT FOR NARROW-BAND ULTRAVIOLET B (NBUVB) TREATMENT

080560 : CONSENT FOR ADMINISTRATION OF ANESTHESIA CARE

080560S : THE ADMINISTRATION OF ANESTHESIA CARE

080761 : CONSENT FOR VAGINAL BIRTH AFTER CESAREAN (VBAC) DELIVERYAND ADMINISTRATION OF ANESTHESIA OR SEDATION

080871 : DEPARTMENT OF RADIOLOGY – CONSENT FOR BIOPSY

081065 : CONSENT FOR TRANSRECTAL ULTRASOUND GUIDED (TRUS) PROSTATE BIOPSY

081166 : PAIN MANAGEMENT - CONSENT FOR EPIDURAL STEROID INJECTION PROCEDURES

081167 : CONSENT FOR PROCEDURES IN THE ADULT INTENSIVE CARE UNITS

081168 : DIGESTIVE HEALTH CENTER - CONSENT FOR UPPER ENDOSCOPY WITH FLUORESCEIN DYE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

081169 : CONSENT FOR ERCP AND/OR EUS-GUIDED ERCP AND ADMINISTRATION OF ANESTHESIA OR SEDATION

081170 : PEDIATRIC HEMATOLOGY ONCOLOGY CONSENT

081177 : LIVING KIDNEY DONOR INFORMED CONSENT FOR SURGERY

081178 : LIVING KIDNEY DONOR AGREEMENT OF UNDERSTANDING

081179 : DIGESTIVE HEALTH CENTER CONSENT FOR ERCP AND USE OF COVEREDSELF-EXPANDABLE METAL STENTS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

081182 : LIVING LIVER DONOR INFORMED CONSENT FOR MEDICAL/SURGICAL

081183 : LIVING LIVER DONOR AGREEMENT OF UNDERSTANDING

081261 : CONSENT FOR SPINAL SURGERY - ANTERIOR/LATERAL THORACIC

081262 : CONSENT FOR SPINAL SURGERY - ANTERIOR/LATERAL LUMBOSACRAL

081263 : CONSENT FOR SPINAL SURGERY - ANTERIOR CERVICAL

081264 : CONSENT FOR SPINAL SURGERY- COMBINED ANTERIOR THORACOABDOMINAL APPROACH - AND ADMINISTRATION OF ANESTHESIA

081265 : CONSENT FOR SPINAL SURGERY- POSTERIOR SPINE SURGERY

081271 : DIGESTIVE HEALTH CENTER – CONSENT FOR COLONOSCOPY WITH FLUORESCEIN DYE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

090165 : CONSENT FOR DIGESTIVE HEALTH CENTER – THERAPEUTIC PARACENTESIS

090361 : CONSENT FOR ADENOTONSILLECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

090362 : CONSENT FOR BILATERAL MYRINGOTOMY AND TYMPANOSTOMY TUBESAND ADMINISTRATION OF ANESTHESIA OR SEDATION

090363 : CONSENT FOR BOTULINUM TOXIN (BOTOX) INJECTION

090467 : CONSENT FOR RIGHT HEART CATHETERIZATION AND EXERCISE STRESS TEST

090662 : CONSENT FOR SINGLE BALLOON ENTEROSCOPY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

090760 : CONSENT – NOTICE OF INTENT TO PERFORM ABORTION ON A MINOR

090961 : CONSENT- SLEEP APNEA PATIENT AGREEMENT

091062 : INTERVENTIONAL RADIOLOGY – CONSENT FOR CENTRAL LINE PLACEMENT

091078 : 24 HOUR ACKNOWLEDGEMENT NOTIFICATION

100360 : CONSENT FOR INTRAATHECAL PUMP REFILL AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100361 : CONSENT FOR SPINAL CORD STIMULATOR IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100362 : CONSENT FOR INTRATHECAL PUMP IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100364 : CONSENT FOR JOINT ASPIRATION WITH INJECTION OF CONTRAST

100463 : HEART RECIPIENT INFORMED CONSENT FOR SUREGERY AND/OR ADMINISTRATION OF ANESTHESIA OR SEDATION

100464 : LUNG RECIPIENT INFORMED CONSENT FOR SURGERY AND/OR ADMINISTRATION OF ANESTHESIA OR SEDATION

100465 : LIVER RECIPIENT INFORMED CONSENT FOR SURGERY

100466 : KIDNEY/PANCREAS RECIPIENT INFORMED CONSENT FOR SURGERYAND /OR ADMINISTRATION OF ANESTHESIA OR SEDATION

100467 : CONSENT FOR PERIPHERAL NERVE STIMULATOR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100468 : CONSENT FOR PERIPHERAL NERVE STIMULATOR- TRIAL AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100469 : CONSENT FOR MAGNETIC RESONANCE IMAGERY (MRI), GUIDED FOCUS ULTRA SOUND OF UTERUS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100564 : CONSENT FOR SYMPATHETIC GANGLION BLOCK PROCEDURE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100567 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100568 : CONSENT FOR CATARACT EXTRACTION WITH LENS IMPLANT AND DSAEK DESCEMET’S STRIPPING AUTOMATED ENDOTHELIAL KERATOPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100570 : CONSENT FOR EYLEA MEDICATION INJECTION INTO THE EYE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100571 : CONSENT FOR AVASTIN MEDICATION INJECTION INTO THE EYE (POD)

100666 : CONSENT FOR BALLOON-OCCLUDED RETROGRADE TRANSVENOUS OBLITERATION (BRTO) OF GASTRIC VARICES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100667 : CONSENT FOR PENETRATING KERATOPLASTY - INTRAOCULAR LENS IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100863 : CANCER GENETICS CLINIC INFORMED CONSENT FOR DNA BANKING

100960 : CONSENT FOR Optomap PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

100961 : CONSENT FOR MEDICAL BRANCH NERVE BLOCK PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

101160 : CONSENT TO RADIATION THERAPY: CENTRAL NERVOUS SYSTEM

101161 : CONSENT TO RADIATION THERAPY: BREAST

101162 : CONSENT TO RADIATION THERAPY: ABDOMEN

101163 : CONSENT TO RADIATION THERAPY: TOTAL BODY

101164 : CONSENT TO RADIATION THERAPY: THORAX

101165 : CONSENT TO RADIATION THERAPY: SKIN

101166 : CONSENT TO RADIATION THERAPY: MALE PELVIS

101167 : CONSENT TO RADIATION THERAPY: HEAD AND NECK AND ADMINISTRATION OF ANESTHESIA OR SEDATION

101168 : CONSENT TO RADIATION THERAPY: GYN IMPLANT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

101169 : CONSENT TO RADIATION THERAPY: FEMALE PELVIS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

101170 : CONSENT TO RADIATION THERAPY: EXTREMITIESAND ADMINISTRATION OF ANESTHESIA OR SEDATION

110460 : CONSENT FOR MAGNETIC RESONANCE IMAGING IN A PATIENT WITH A PERMANENT PACEMAKER AND/OR IMPLANTABLE CARDIOVERTER DEFIBRILLATOR

110961 : CONSENT FOR USE OF DONOR HUMAN MILK

111160 : CONSENT FOR ALLOGENEIC STEM CELL TRANSPLANTATION OF RELATED OR UNRELATED STEM CELL GRAFT

111261 : CONSENT FOR AUTOLOGOUS HEMATOPOIETIC PROGENITOR CELL (STEM CELL) TRANSPLANT

111262 : CONSENT FOR STEM CELL APHRESIS

111263 : CONSENT FOR ORTHOPEDIC SURGERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120466 : CONSENT FOR THERAPEUTIC APHERESIS AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120467 : DENTISTRY CONSENT FOR BONE GRAFT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120860 : CONSENT FOR CLOSURE OF ATRIAL SEPTAL DEFECT BY PERCUTANEOUS APPROACH PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120861 : CONSENT FOR LAPAROSCOPIC GASTRIC BYPASS PROCEDURES AND

120862 : CONSENT FOR LAPAROSCOPIC ADJUSTABLE BAND PROCEDURES AND

120863 : CONSENT FOR LAPAROSCOPIC SLEEVE GASTRECTOMY PROCEDURES

120864 : CONSENT FOR LAPAROSCOPIC BAND ADJUSTMENT PROCEDURES

120865 : CONSENT FOR ABDOMINAL MASS RESECTION PROCEDURES

120866 : CONSENT FOR BILE DUCT RESECTION - BENIGN PROCEDURES

120867 : CONSENT FOR BILE DUCT RESECTION - NEOPLASM PROCEDURES

120868 : CONSENT FOR DISTAL PANCREATECTOMY FOR NEOPLASM PROCEDURES

120869 : CONSENT FOR DISTAL PANCREATECTOMY FOR PANCREATITIS

120870 : CONSENT FOR DUODENAL LESION RESECTION PROCEDURES ANDADMINISTRATION OF ANESTHESIA OR SEDATION

120871 : CONSENT FOR HEPATECTOMY FOR NEOPLASM IN CIRRHOSIS PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120872 : CONSENT FOR HEPATECTOMY FOR NEOPLASM IN NORMAL LIVER PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120873 : CONSENT FOR PARTIAL GASTRECTOMY FOR ULCERS PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120874 : CONSENT FOR PARTIAL GASTRECTOMY FOR NEOPLASM PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120875 : CONSENT FOR SPLENECTOMY PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120876 : CONSENT FOR TOTAL GASTRECTOMY FOR NEOPLASM PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120877 : CONSENT FOR WHIPPLE PROCEDURE FOR AMPULLARY NEOPLASM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120878 : CONSENT FOR MEDICAL/SURGICAL PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120879 : CONSENT FOR MEDICAL/SURGICAL PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120880 : CONSENT FOR NEXPLANON® IMPLANT

120881 : CONSENT FOR CEREBRAL ANGIOGRAPHY WITH OR WITHOUT ANGIOPLASTY WITH OR WITHOUT INTRA-ARTERIAL ADMINISTRATION OF MEDICATION FOR TREATMENT OF VASOSPASM WITH OR WITHOUT VASCULAR CLOSURE DEVICE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

120961 : CONSENT FOR FECAL MICROBIOTA TRANSPLANT PROCEDURES

121061 : CONSENT FOR VAGINAL MESH EXCISION - INTRA-ABDOMINAL OR VAGINAL -AND ADMINISTRATION OF ANESTHESIA OR SEDATION

121062 : CONSENT FOR URETHRAL OR VAGINAL MASS EXCISION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

121063 : CONSENT FOR STAGE II SACRAL NERVE STIMULATION, IMPLANTATION OFPULSE GENERATOR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

121064 : CONSENT FOR STAGE I TINED LEAD IMPLANTATION TRIAL SACRAL NERVESTIMULATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

121065 : CONSENT FOR ROBOTIC SACROCOLPOPEXY AND/OR HYSTERECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

121066 : CONSENT FOR ROBOTIC RECTOVAGINAL FISTULA REPAIR AND/OR ANAL SPHINCTEROPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130161 : HEART AND VASCULAR CENTER UVA CARDIOPULMONARY REHABILITATION AND WELLNESS PROGRAM INFORMED CONSENT

130261 : CONSENT FOR ANORECTAL SURGERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130262 : CONSENT FOR OPEN COLON RESECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130263 : CONSENT FOR OPEN LEFT COLON/RECTAL RESECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130264 : CONSENT FOR ALTMEIR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130265 : CONSENT FOR LAPARASCOPIC LEFT COLON/RECTAL RESECTION/POSSIBLE OPEN LEFT COLON/RECTAL RESECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130266 : CONSENT FOR LAPAROSCOPIC COLON RESECTION/POSSIBLE OPEN COLON RESECTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130361 : CONSENT FOR TRANSANAL ENDOSCOPIC MICROSURGERY OF RECTAL NEOPLASM AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130560 : CONSENT FOR INGUINAL HERNIA REPAIR WITH MESH ANDADMINISTRATION OF ANESTHESIA OR SEDATION

130561 : CONSENT FOR VENTRAL HERNIA REPAIR WITH MESH AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130562 : CONSENT FOR LAPAROSCOPIC CHOLECYSTECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130563 : CONSENT FOR UMBILICAL HERNIA REPAIR WITH MESH AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130665 : CONSENT FOR PEDIATRIC AND CONGENITAL CARDIAC CATHETERIZATION AND POSSIBLE INTERVENTION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

130761 : CONSENT FOR ADMINISTRATION OF RADIOACTIVE RADIUM-223 CHLORIDE XOFIGO) THERAPY FOR PROSTATE CANCER SPREAD TO BONE

130762 : CONSENT FOR LEAD EXTRACTION PROCEDURE ANDADMINISTRATION OF ANESTHESIA OR SEDATION

130860 : CONSENT FOR LUMENIS M22 LASER TREATMENT

140262 : CONSENT FOR SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140263 : CONSENT FOR SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR GENERATOR CHANGE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140361 : CONSENT TO CHANGE PERSONAL HEALTH INFORMATION PREFERENCE

140560 : CONSENT FOR LASER PHOTOCOAGULATION

140662 : CONSENT FOR REMOVAL OF RADIOACTIVE PLAQUE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140663 : CONSENT FOR RETINAL SURGERY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140665 : CONSENT FOR PERCUTANEOUS TRACHEOSTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140760 : CONSENT FOR PLACEMENT OF RADIOACTIVE PLAQUE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

140861 : CONSENT FOR DONOR LEUKOCYTE INFUSION

150160 : CONSENT FOR MRI SCAN OF A PREGNANT PATIENT: WITH GADOLINIUM ADMINISTRATION

150360 : DONOR CONSENT FOR STEM CELL APHERESIS (COLLECTION)

150362 : CONSENT FOR LASER IRIDOTOMY PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150363 : CONSENT FOR YAG LASER CAPSULOTOMY PROCEDURES AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150460 : CONSENT FOR PHOTO-DYNAMIC THERAPY (PDT-LIGHT) LASER TREATMENT AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150560 : DECLARATION OF URGENT MEDICAL NEED FROM DONOR

150561 : DECLARATION OF URGENT MEDICAL NEED FROM RECIPIENT

150660 : CONSENT FOR IMPLANTATION OF A LEFT ATRIAL APPENDAGE CLOSURE DEVICE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150662 : CONSENT FOR PEDIATRIC SEDATION FOR RADIOLOGIC IMAGING

150860 : CONSENT FOR LUCENTIS MEDICATION INJECTION INTO THE EYE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150861 : CONSENT TO PHOTOGRAPH AND/OR VIDEO

150862 : Consent for Percutaneous Mitral Valve Repair/Replacement and Administration of Anesthesia or Sedation

150864 : CONSENT FOR TRANSCATHETER AORTIC VALVE REPLACEMENT / IMPLANTATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

150962 : CONSENT FOR TRANSCRANIAL MAGNETIC STIMULATION

151060 : CONSENT FOR DESCEMET'S STRIPPING AND AUTOMATED ENDOTHELIAL KERATOPLASTY PROCEDURES

151063 : CONSENT FOR PEDIATRIC COLONOSCOPY WITH BIOPSY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

151064 : CONSENT FOR PEDIATRIC ESOPHAGOGASTRODUODENOSCOPY

160162 : CONSENT FOR SPORTS HERNIA REPAIR AND ADMINISTRATION OF ANESTHESIA OR SEDATION

160163 : CONSENT FOR MAGNETIC RESONANCE IMAGING (MRI) IN A PATIENT WITH IVES EEG LEADS

160460 : CONSENT FOR RIGHT HEART CATHETERIZATION AND IMPLANTATION OF A PRESSURE SENSING DEVICE

160461 : CONSENT FOR OPHTHALMIC ANGIOGRAPHY

160463 : CONSENT FOR LAPAROSCOPIC STERILIZATION AND ADMINISTRATION OF ANESTHESIA OR SEDATION

160661 : CONSENT FOR APHERESIS (BLOOD COMPONENT COLLECTION)

160801 : CONSENT FOR ORCHIOPEXY PROCEDURE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

160802 : CONSENT FOR MEATOTOMY PROCEDURE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

160803 : CONSENT FOR CYSTOSCOPY AND PYLOPLASTY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

160804 : CONSENT FOR PEDIATRIC URETERAL RE-IMPLANT PROCEDURE AND ADMINISTRATION OF ANESTHESIA OR SEDATION

170206 : CONSENT FOR THE PROCESSING, FREEZING AND STORAGE OF CELLULAR PRODUCTS AT THE UNIVERSITY OF VIRGINIA HEMATOPOIETIC PROGENITOR CELL TRANSPLANTATION (HSCT)PROGRAM

170302 : SHENANDOAH NEPHROLOGY - CONSENT FOR DIALYSIS THERAPY IN ACUTE KIDNEY INJURY

170303 : DIVISION OF NEPHROLOGY - CONSENT FOR DIALYSIS THERAPY IN ACUTE KIDNEY INJURY

170304 : LYNCHBURG NEPHROLOGY PRACTICE – CONSENT FOR DIALYSIS THERAPY IN ACUTE KIDNEY INJURY

170305 : CENTRA HEALTH, INC. – CONSENT FOR DIALYSIS THERAPY IN ACUTE KIDNEY INJURY

170306 : CONSENT FOR VENDOR TO OBSERVE, PHOTOGRAPH AND/OR VIDEO PATIENT CARE

170307 : SHENANDOAH NEPHROLOGY - CONSENT FOR DIALYSIS CHRONIC KIDNEY DISEASE, STAGE 5

170308 : DIVISION OF NEPHROLOGY –CONSENT FOR DIALYSIS CHRONIC KIDNEY DISEASE, STAGE 5

170309 : LYNCHBURG NEPHROLOGY PRACTICE – CONSENT FOR DIALYSIS CHRONIC KIDNEY DISEASE, STAGE 5

170310 : CENTRA HEALTH, INC. –CONSENT FOR DIALYSIS CHRONIC KIDNEY DISEASE, STAGE 5

170401 : CONSENT FOR EXERCISE STRESS TEST WITH POSSIBILITY OF CONVERTING TO VASODILATOR STRESS TEST

170609 : CONSENT FOR RENAL REPLACEMENT THERAPY

170802 : ALLOGENEIC DONOR CONSENT FOR BONE MARROW HARVEST

170901 : AUTOLOGOUS DONOR CONSENT FOR BONE MARROW HARVEST

171001 : CONSENT FOR NECK DISSECTION WITH TOTAL THYROIDECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

171002 : CONSENT FOR TREATMENT OF TOTAL THYROIDECTOMY AND ADMINISTRATION OF ANESTHESIA OR SEDATION

180101 : CONSENT FOR EXTRACORPOREAL PHOTOPHORESIS (ECP)

180201 : CONSENT FOR ORAL FOOD CHALLENGE

180203 : CONSENT FOR NEEDLE LOCALIZATION

180302 : CONSENT FOR DRUG CHALLENGE

180701 : CONSENT FOR THE PROCESSING, FREEZING AND STORAGE OF IMMUNE EFFECTOR CELL (IEC) PRODUCTS

000319 CONSENT FOR RIGHT HEART CATHETERIZATION AND/OR BIOPSY

181501 : Consent for Drug Desensitization

190101 : Consent for Percutaneous Tricuspid Valve Repair/Replacement and Administration of Anesthesia or Sedation

190402 : Blood Transfusion Refusal/Partial Acceptance

190503 : Consent for Puberty Blockers

Chapter 3 : Downtime Forms

Section A : Adult Acute Care

000324 : DOWNTIME CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT “CIWA”

000404 : DOWNTIME HISTORY AND PHYSICAL

001013 : DOWNTIME NON-BEHAVIORAL RESTRAINT FLOWSHEET

030407 : EMR DOWNTIME ORDER

030863 : DOWNTIME PATIENT’S PROGRESS NOTES

031215 : DOWNTIME ADULT ACUTE CARE INSULIN INFUSION FLOW SHEET

031220 : DOWNTIME ACUTE CARE NEURO CHECK FLOW SHEET

33006 : DOWNTIME CONSULTATION REQUEST

33022 : DOWNTIME MEDS ORDER FORM FOR LIPS

033033 : DOWNTIME PREOPERATIVE/PREPROCEDURE CHECKLIST

33290 : DOWNTIME PATIENT'S PROGRESS NOTES

040169 : DOWNTIME SOCIAL WORK PSYCHOSOCIAL ASSESSMENT

050101 : DOWNTIME ADULT ACUTE CARE SYSTEMS ASSESSMENT

050102 : DOWNTIME ADULT CLINICAL DATA FLOWSHEET

050103 : DOWNTIME ADULT ADMISSION SCREENING DATABASE

080361 : DOWNTIME PATIENT MEDICATION LIST

090468 : UVa DOWNTIME TOOL TO IDENTIFY PATIENTS AT RISK FOR OBSTRUCTIVE SLEEP APNEA

120464 : DOWNTIME MEDICATION ADMINISTRATION RECORD (MAR)

120465 : DOWNTIME AFTER VISIT SUMMARY/DISCHARGE REPORT

130171 : PSYCHIATRIC SERVICES DOWNTIME ADDENDUM TO THE ADULT ACUTE CARE SYSTEMS ASSESSMENT

130260 : DOWNTIME RADIOLOGY RECTAL CONTRAST SCREENING FORM

181001 : DOWNTIME VIOLENT RESTRAINT FLOWSHEET

Section B : Adult Intensive Care

000404 : DOWNTIME HISTORY AND PHYSICAL

001013 : DOWNTIME NON-BEHAVIORAL RESTRAINT FLOWSHEET

020220 : DOWNTIME CRITICAL CARE SYSTEMS ASSESSMENT

021294 : DOWNTIME CRITICAL CARE FLOW SHEET

030407 : EMR DOWNTIME ORDER

030863 : DOWNTIME PATIENT’S PROGRESS NOTES

33006 : DOWNTIME CONSULTATION REQUEST

33022 : DOWNTIME MEDS ORDER FORM FOR LIPS

33290 : DOWNTIME PATIENT'S PROGRESS NOTES

040169 : DOWNTIME SOCIAL WORK PSYCHOSOCIAL ASSESSMENT

040487 : DOWNTIME ADULT RESPIRATORY THERAPY NOTE

050103 : DOWNTIME ADULT ADMISSION screening DATABASE

050462 : DOWNTIME RESPIRATORY THERAPY MONITORING FLOWSHEET

100363 : ICU DOWNTIME PATIENT CARE PLANNING ROUNDS

120464 : DOWNTIME Medication Administration Record (MAR)

1811001 : DOWNTIME VIOLENT RESTRAINT FLOWSHEET

190201 : Blood Administration NOT Documented in EPIC

Section C : Ambulatory

010219 : DOWNTIME CLINICAL ENCOUNTER NOTE

050105 : DOWNTIME PATIENT AND FAMILY EDUCATION (AMBULATORY / SUPPLEMENTAL)

050479 : OBSTETRICS AND GYNECOLOGY - DOWNTIME OUTPATIENT ENCOUNTER - PHYSICAL EXAMINATION

070165 : DOWNTIME AMBULATORY HANDOFF OF CARE REPORT

081267 : DOWNTIME SURGICAL SAFETY ADMISSION TICKET

100101 : DOWNTIME INITIAL INTAKE

100264 : DOWNTIME EBT - EMOTIONAL BRAIN THERAPY COACHING SESSION

100861 : DOWNTIME RETURN TO WORK, SCHOOL, OR NORMAL DUTIES

100866 : DOWNTIME UPG ENCOUNTER FORM - AMBULATORY

130666 : AMBULATORY CLINICAL SUPPORT DOWNTIME WORKSHEET

190201 : Blood Administration NOT Documented in Epic

Section D : Ambulatory Ophthalmology

100479 : DOWNTIME RETINA CLINIC FOLLOW-UP VISIT

100574 : DOWNTIME CORNEA SERVICE FOLLOW-UP VISIT

100576 : DOWNTIME GLAUCOMA FOLLOW-UP EXAM

100679 : DOWNTIME OPHTHALMOLOGY INITIAL VISIT

100680 : DOWNTIME OPHTHALMOLOGY RESIDENT CLINIC F/U EXAM

190201 : Blood Administration NOT documented in EPIC

Section E : Care Planning

030975 : DOWNTIME PEDIATRIC CRITICAL/ACUTE/REHABILITATION CARE

050104 : DOWNTIME INTERDISCIPLINARY TEAM — PATIENT CARE PLANNING ROUNDS

100363 : ICU DOWNTIME PATIENT CARE PLANNING ROUNDS

100401 : DOWNTIME DAILY CARE PLAN

100462 : PICU DOWNTIME — PATIENT CARE PLANNING ROUNDS

Section F : Event

030470 : DOWNTIME CODE 12 EVENT RECORD

061063 : DOWNTIME EMERGENCY RESPONSE RECORD

Section G : Discharge

000228 : DOWNTIME POST-SEDATION / POST-PROCEDURE DISCHARGE INSTRUCTIONS

000228S : DOWNTIME POST SEDATION / POST PROCEDURE DISCHARGE INSTRUCTIONS (Spanish)

050664 : DOWNTIME POSTOPERATIVE / POST PROCEDURE DISCHARGE INSTRUCTIONS

050664s : DOWNTIME POSTOPERATIVE / POST PROCEDURE DISCHARGE INSTRUCTIONS (Spanish)

060161 : DEPARTMENT OF RADIOLOGY DOWNTIME DISCHARGE INSTRUCTIONS FOR IV CONTRAST INJECTION

060365 : DOWNTIME NEURORADIOLOGY VERTEBROPLASTY DISCHARGE INSTRUCTIONS

061001 : “WE’RE GOING HOME” FOR _______________________ DOWNTIME FAMILY DISCHARGE INSTRUCTIONS

120465 : DOWNTIME AFTER VISIT SUMMARY/DISCHARGE REPORT

Section H : ED (Emergency Department)

030764 : DOWNTIME EMERGENCY DEPARTMENT SCREENING ASSESSMENT

030863 : DOWNTIME PATIENT’S PROGRESS NOTES

031020 : DOWNTIME TRAUMA FLOW SHEET

031079 : EMERGENCY DEPARTMENT - DOWNTIME TRAUMA SERVICE HISTORY AND PHYSICAL

33015 : DOWNTIME EMERGENCY DEPARTMENT – DISCHARGE INSTRUCTION SHEET

33015s : EMERGENCY DOWNTIME DISCHARGE INSTRUCTION SHEET (SPANISH)

33022 : DOWNTIME MEDS ORDER FORM FOR LIPS

33180 : DOWNTIME EMERGENCY DEPARTMENT RECORD

33305 : EMERGENCY DOWNTIME DEPARTMENT RECORD OBSERVATION REASSESSMENT/PROCEDURE FLOW SHEET

33306 : EMERGENCY DEPARTMENT—DOWNTIME ADULT NURSING ASSESSMENT

33308 : DOWNTIME PEDIATRIC NURSING ASSESSMENT

33309 : EMERGENCY DEPARTMENT DOWNTIME OBSERVATION FLOW SHEET

33357 : EMERGENCY DEPARTMENT – DOWNTIME HISTORY AND PHYSICAL

070968 : DOWNTIME EMERGENCY DEPARTMENT MEDICATION LIST - RECONCILIATION FORM

190201 : Blood Administration Not Documented In Epic

Section I : Flowsheet

030187 : DOWNTIME POST ANESTHESIA RECOVERY RECORD

030275 : DOWNTIME CRRT FLOWSHEET

080962 : DOWNTIME RENAL SERVICES – CAPD FLOWSHEET

Section J : LIP

000404 : DOWNTIME HISTORY AND PHYSICAL

001014 : DOWNTIME PULMONARY FUNCTION LABORATORY REQUEST

030561 : UVA CHILDREN’S HOSPITAL – DOWNTIME ADMISSION HISTORY AND PHYSICAL

031087 : DOWNTIME SOCIAL WORK ASSESSMENT - REPORT OF SUSPECTED ADULT ABUSE/NEGLECT

33006 : DOWNTIME CONSULTATION REQUEST

33290 : DOWNTIME PATIENT'S PROGRESS NOTES

050978 : DOWNTIME MEDICAL ORDER DOCUMENTATION

100266 : DOWNTIME DURABLE MEDICAL EQUIPMENT (DME) REFERRAL

110309 : DOWNTIME FACE-TO-FACE ENCOUNTER ATTESTATION for HOME HEALTH SERVICES

120460 : DOWNTIME SLEEP STUDY ORDER- NEURO

120461 : DOWNTIME SLEEP STUDY ORDER - PEDIATRIC

120462 : DOWNTIME SLEEP STUDY ORDER-ADULT

Section K : Medication

33022 : Downtime PHYSICIAN’S ORDER FORM

Downtime Prescription Form

Section L : NICU/PICU

030863 : DOWNTIME PATIENT’S PROGRESS NOTES

080105 : DOWNTIME NEONATAL ICU FLOW SHEET

120470 : NICU DOWNTIME MULTI-DISCIPLINARY DISCHARGE FLOWSHEET

Section M : Procedure

010414 : DOWNTIME HYPERBARIC OXYGEN (HBO) MEDICINE SERVICE TRANSCUTANEOUS OXIMETRY ASSESSMENT UE - HEAD

010415 : DOWNTIME HYPERBARIC OXYGEN (HBO) MEDICINE SERVICE TRANSCUTANEOUS OXIMETRY ASSESSMENT LE

010416 : DOWNTIME HYPERBARIC OXYGEN (HBO) MEDICINE SERVICE TRANSCUTANEOUS OXIMETRY ASSESSMENT TRUNK

031081 : RENAL UNIT – DOWNTIME HEMODIALYSIS FLOWSHEET

031215 : DOWNTIME ADULT ACUTE CARE INSULIN INFUSION FLOW SHEET

033033 : DOWNTIME PREOPERATIVE/PREPROCEDURE CHECKLIST

33620 : DOWNTIME NUCLEAR CARDIOLOGY & STRESS ECG REQUEST

040564 : ANGIO/INTERVENTIONAL RADIOLOGY DOWNTIME - PRE-PROCEDURAL ASSESSMENT

040680 : RENAL UNIT - DOWNTIME APHERESIS FLOWSHEET

050475 : DOWNTIME PRE-PROCEDURE CHECKLIST – AMBULATORY / BEDSIDE

050680 : DOWNTIME OUTPATIENT SURGERY ANESTHESIA RECORD

060163 : DOWNTIME CONTRAST REACTION REPORTING FORM

080173 : RADIOLOGY DOWNTIME ORAL CONTRAST SCREENING FORM

080868 : DOWNTIME UVA OUTPATIENT SURGERY CENTER DATA RECORD

090273 : NURSING INTERVENTIONAL RADIOLOGY DOWNTIME PROCEDURAL FLOWSHEET

090664 : DOWNTIME CENTRAL LINE INSERTION

100161 : DOWNTIME POST PROCEDURAL FLOWSHEET (continuation of procedure note / form # 000225)

120560 : DOWNTIME IV CONTRAST (DYE) SCREENING FORM

120561 : DOWNTIME RADIOLOGY MRI SCREENING SHEET

121068 : PERIOPERATIVE DOWNTIME FLOWSHEET

121162 : DOWNTIME TELEPHONE CONTRACT SHEET FOR SURGERY PATIENTS

130260 : DOWNTIME RADIOLOGY RECTAL CONTRAST SCREENING FORM

140163 : DOWNTIME PET SCREENING FORM

170610 : DOWNTIME BRIEF OP NOTE

190201 : Blood Administration NOT Documented In Epic

Section N : Psychiatry

010101 : DOWNTIME PSYCHIATRIC SERVICES—ADULT CLINICAL DATA FLOW SHEET

010102 : DOWNTIME PSYCHIATRY SERVICES MULTIDISCIPLINARY CONTINUING CARE AND DISCHARGE PLANNING TOOL

010821 : DOWNTIME PSYCHIATRY SERVICES ADMISSION INTAKE SCREENING

010823 : DOWNTIME PSYCHIATRIC PSYCHOSOCIAL ADMISSION ASSESSMENT - PART 3

010825 : DOWNTIME PSYCHIATRY SERVICES Occupational Therapy ADMISSION ASSESSMENT (PART 2)

011022 : PSYCHIATRIC SERVICES - DOWNTIME INPATIENT INTERDISCIPLINARY TREATMENT PLAN (PART 1)

020204 : PSYCHIATRY SERVICES DOWNTIME INTERDISCIPLINARY TREATMENT PLAN COMPREHENSIVE TREATMENT PLAN

020320 : PSYCHIATRY SERVICES – DOWNTIME INTERDISCIPLINARY TREATMENT PLAN

020913 : INPATIENT PSYCHIATRY — DOWNTIME PATIENT ASSESSMENT/REASSESSMENT

33022 : DOWNTIME MEDS ORDER FORM FOR LIPS

130172 : PSYCH DOWNTIME DAILY CARE PLAN

Section O : RT (Respiratory Therapy)

030976 : DOWNTIME NICU RESPIRATORY THERAPY PROGRESS NOTE

040487 : DOWNTIME ADULT RESPIRATORY THERAPY NOTE

050462 : DOWNTIME RESPIRATORY THERAPY MONITORING FLOWSHEET

Section P : SW (Social Work)

031087 : DOWNTIME SOCIAL WORK ASSESSMENT - REPORT OF SUSPECTED ADULT ABUSE/NEGLECT

33377 : SOCIAL WORK - DOWNTIME SUSPECTED CHILD ABUSE AND NEGLECT REPORT

33380 : DOWNTIME PHYSICIAN - SUSPECTED CHILD ABUSE AND NEGLECT REPORT

040168 : DOWNTIME SOCIAL WORK BRIEF PSYCHOSOCIAL NOTE

040169 : DOWNTIME SOCIAL WORK PSYCHOSOCIAL ASSESSMENT

Section Q : TCH (Transitional Care Hospital)

000912 : DOWNTIME PHYSICAL THERAPY SERVICES - PHYSICAL THERAPY EXAMINATION

030761 : DOWNTIME OCCUPATIONAL THERAPY EVALUATION - OCCUPATIONAL PROFILE

100477 : DOWNTIME STATEMENT OF PROVIDER OPTIONS FOR FAMILY TRANSITIONAL CARE

100478 : DOWNTIME DISCHARGE PLAN-- TRANSITIONAL CARE HOSPITAL

100661 : TCH DOWNTIME ATTENDING PHYSICIAN DAILY PROGRESS NOTE

100664 : TRANSITIONAL CARE HOSPITAL DOWNTIME CASE MANAGEMENT ASSESSMENT AND DISCHARGE PLAN

100665 : DOWNTIME TCH PATIENT REFERRAL EVALUATION - CLINICAL REASSESSMENT CONSULT

100674 : DOWNTIME TCH ADULT SYSTEMS ASSESSMENT

100760 : DOWNTIME WEEKLY TEAM CONFERENCE CLIENT CARE PLAN

100761 : TCH DOWNTIME UTILIZATION CONTINUED STAY/DISCHARGE REVIEW

100762 : TRANSITIONAL CARE HOSPITAL DOWNTIME UTILIZATION ADMISSION REVIEW

Section R : Therapies - PT/OT/SP

000912 : DOWNTIME PHYSICAL THERAPY SERVICES - PHYSICAL THERAPY EXAMINATION

020403 : SPEECH-LANGUAGE — DOWNTIME PROGRESS NOTE

020520 : DOWNTIME SPEECH-LANGUAGE PATHOLOGY CLINICAL SWALLOWING EVALUATION

020521 : SPEECH-LANGUAGE PATHOLOGY DOWNTIME MODIFIED BARIUM SWALLOW STUDY (MBS)

030761 : DOWNTIME OCCUPATIONAL THERAPY EVALUATION - OCCUPATIONAL PROFILE

060280 : CHILDREN’S HOSPITAL THERAPY SERVICES DOWNTIME OCCUPATIONAL THERAPY PROGRESS NOTE

060283 : DOWNTIME OCCUPATIONAL THERAPY ACUTE PEDS SUPPLEMENTAL TREATMENT GOALS

Section S : Women's/Children's

000225 : DOWNTIME SEDATION/ANALGESIA PROCEDURE NOTE

000413 : DOWNTIME NEWBORN ADMISSION ASSESSMENT

000414 : DOWNTIME NEWBORN DISCHARGE ASSESSMENT

020822 : DOWNTIME LABOR & DELIVERY TRIAGE

030407 : EMR DOWNTIME ORDER

030561 : UVA CHILDREN’S HOSPITAL – DOWNTIME ADMISSION HISTORY AND PHYSICAL

33006 : DOWNTIME CONSULTATION REQUEST

33009 : DOWNTIME LABOR RECORD

33022 : DOWNTIME MEDS ORDER FORM FOR LIPS

33080 : CLINICAL CARE SERVICES IV THERAPY FLOW SHEET

33290 : DOWNTIME PATIENT'S PROGRESS NOTES

040573 : NEWBORN CLINICAL DATA DOWNTIME FLOW SHEET SUPPLEMENTAL

040763 : DOWNTIME OBSTETRIC INSULIN FLOW SHEET

050380 : DOWNTIME OB CLINICAL DATA FLOW SHEET

050381 : DOWNTIME OB SYSTEMS ASSESSMENT

050460 : DOWNTIME PEDIATRIC CLINICAL DATA FLOW SHEET

050560 : DOWNTIME PICU SYSTEMS ASSESSMENT

050663 : DOWNTIME NEWBORN SYSTEMS ASSESSMENT

050684 : DOWNTIME NICU SUPPLEMENTAL DATA RECORD

050978 : DOWNTIME MEDICAL ORDER DOCUMENTATION

051191 : DOWNTIME NEONATAL ICU SYSTEMS ASSESSMENT

051192 : DOWNTIME PEDIATRIC ACUTE CARE SYSTEMS ASSESSMENT

070462 : UVA CHILDREN’S HOSPITAL – OUTPATIENT PEDIATRICS DOWNTIME PATIENT CARE ASSESSMENT

070662 : DOWNTIME DAILY ANTE-PARTUM PROGRESS NOTE

070862 : DEPARTMENT OF OBSTETRICS AND GYNECOLOGY - DOWNTIME LACTATION PROGRESS NOTE

080101 : DOWNTIME PEDIATRIC ADMISSION SCREENING DATABASE

190201 : Blood Administration NOT documented in EPIC

Section T : Radiology Downtime Forms

030189 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING DOWNTIME MRI REQUEST FORM

030190 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING DOWNTIME ULTRASOUND REQUEST FORM

030191 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING DIAGNOSTIC/X-RAY DOWNTIME REQUEST FORM

030192 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING NEURORADIOLOGY DOWNTIME REQUEST FORM

030193 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING FLUOROSCOPY DOWNTIME REQUEST FORM

030373 : DEPARTMENT OF RADIOLOGY AND MEDICAL IMAGING NUCLEAR MEDICINE REQUEST FORM

030374 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING DOWNTIME ANGIO INTERVENTIONAL RADIOLOGY REQUEST FORM

030377 : DEPARTMENT OF RADIOLOGY & MEDICAL IMAGING CT DOWNTIME REQUEST FORM

33006 : DOWNTIME CONSULTATION REQUEST

120560 : DOWNTIME IV CONTRAST (DYE) SCREENING FORM

120561 : DOWNTIME RADIOLOGY MRI SCREENING SHEET

Section U : Laboratory Requistion Forms (not available on demand, forms must be ordered)

Laboratory Requistion Forms

191003 : Downtime Intra-op Documentation

191003 : Off unit OR Documentation

CMS-R-131 (S) : Advance Beneficiary Notice of Noncoverage (Spanish)

080670 : Procedure Endoscopy/Bronchoscopy

110170 : Department of Orthopaedic Surgery Prosthetics Proof Of Delivery

110171 : Department of Orthopaedic Surgery Prosthetic and Orthotics (Battle) Proof of Delivery

130268 : Outside Facility MOHS Surgery Referral Form

190401 : Non Accidental Trauma Infant Skeletal Survey Results Diagram

190501 : Estrogen Therapy Consent

190502 : Consent for Testosterone Therapy

190701 : Dental Clearance and Risk Assessment for UVA Stem Cell Transplant

190702 : Substance Use Assessment Tool-Adults

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