Skip to content. | Skip to navigation

Personal tools

Home > Medical Center > Forms > Clinical Care Forms > Downtime Forms

Chapter 3 : Downtime Forms


Section A : Adult Acute Care

181001 : DOWNTIME VIOLENT RESTRAINT FLOWSHEET

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

130260 : DOWNTIME RADIOLOGY RECTAL CONTRAST SCREENING FORM

130260 : PSYCHIATRIC SERVICES DOWNTIME ADDENDUM TO THE ADULT ACUTE CARE SYSTEMS ASSESSMENT

Section B : Adult Intensive Care

1811001 : DOWNTIME VIOLENT RESTRAINT FLOWSHEET

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)

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

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

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

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

050664 : DOWNTIME POSTOPERATIVE / POST PROCEDURE DISCHARGE INSTRUCTIONS

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)

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

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

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

191002 : Downtime Intra-op Documentation

191003 : Downtime Intra-op Documentation

191003 : Off unit OR Documentation

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

Document Actions

Clinical Form Request

To request a new revision of a Clinical form visit the HIS website.

 

To order multiple copies:

 

  1. Search for and choose the appropriate document. 
  2. Right click the document PDF
  3. Select “Copy shortcut”
  4. Send an email with the PDF form attached to hospcopy@virginia.edu and include the following information:
    • Your name
    • PTAO
    • Quantity
    • Contact/Delivery information

 

PLEASE INCLUDE SPECIFIC PRINTING INSTRUCTIONS (i.e. multi part form, NCR, etc...)