Name: Date: _ Years of Experience :
|
|
|
- Bartholomew Scott Osborne
- 5 years ago
- Views:
Transcription
1 R!.~.~~' 21"1:Ploor N New York, NY G Operating Room Nursing Skills Checklist Name: ate: Years of Experience : Use the following key as a guideline: A) Theory Only/No Experience-idactic instruction only, no hands on experience B) Limited Experience-Knows procedure/has used equipment, but has done so infrequently or not within the last six months C) Moderate Experience--Able to demonstrate equipment/procedure, performs the task/skill independently with only resource assistance needed. ) Proficient/Competent--Able to demonstrate/perform the task/skill proficiently without any assistance and can instruct/teach. SCRUB CIRCULATE GENERAL Gastroscopy Gastrectomy Colostomyllleostomy Cholecystectomy Hemorroidectomy Appendectomy Sigmoidoscopy Hepatic resection Herniorraphv Radical Mastectomy Hemicolectomy Bowel Resection AP Resection Thyroidectomy Whipple Procedure Organ Procurement NEUROLOGICAL CARIOVASCULAR Coronary Artery Bypass Graft Cardiac Valve Replacement Transplant Surgery Thoracic Aneurysm
2 CARIOVASCULAR CON'T Atrial Septal efect Surqerv Abdominal Aortic Aneurysm A-V Shunts Porta-Systemic Shunt Pericardial Windows Pacemaker insertions Intra-Aortic Balloon Pump Catheter Femoral - Popliteal Bypass Thrombectomy Vena Cava Lioation Aorto-Femoral Bypass.Graft Insertion THORACIC Chest Tube Insertion Tracheotomy Laryngoscopy Bronchoscopy Thoracotomy Lobectomy/Pneumonectomy Wedge Resection Hiatal Hernia ORTHOPEIC Total Joint Replacement Knee Hip Shoulder Arthroscoov/Arthrotornv Amputation - Leg/Arm Fracture Using AO Compression Patellectomv Closed Pinninq/Reduction O.R.I.F. Tendon Implants/Reanastomosis Spinal Fusion/Harrington Rods OBSTETRICAL/GYNECOLOGIC Hysterectomy &C Gynecologic Laser Procedure Caesarean section Laparoscopy Colposcopy Vulvectomy Radium Insertion Salplnoo - Oophorectomy Tubal - Lioation Termination of Pregnancy Vaginectomy
3 EYE,EAR,NOSE,THROAT Tonsillectomy! Adenoidectomy Odontectomy Stapedectomy Myringotomy Larynegectomy Mastoidectomy Corneal Transplant Retinal etachment Cataract Mandibular Vitrectomy Caldwell-Luc Extraction Ethymoidectomy Radical Neck Resection Nasal Polypectomy PLASTICS Skin Grafts Treatment Tissue Expander of Burn Patients Flap or Pedicle Grafts Split Thickness Mammoplasty Rhytidectomy ermabrasion Blepharoplasty Scar Revision Rhinoplasty Mvelomeninqocele Cleft Lip!Palate Abdominoplasty Liposuction Reduction Insertion of Facial Fracture GENITOURINARY Vasectomy Nephrectomv Cystoscopy Vasovasostomy Penile Implant Insertion Renal Transplant Ileal Loop Circumcision Lithotripsy Orchiectomy Prostatectomy TURPITURB
4 EQUIPMENT Bear I Bear I! Bear V Bennett 7200 CPAP Emerson Enostrom/lirica EMV MA-I MA-II Monihan Ohio 560 PEEP Pressure Pre-Set Servo 900b Servo 900c Servo 900e Hewlett-Packard Soacelab Siemens Marquette Mennen Lifecare Nikon-Koder TA 30 or Roticulator 30 TA 30-V3 or Roticulator 40-V3 TA 55 or Roticulator 55 TA90 GIA-Type CEEA 21 EEA-21 Purstrinc- Tvoe Powered LS Suruictlo- Tvne FS Skin Stapler Poly Surqicltp ermatome-type Hall Micro-ototome Codeman rill Hall Sternal Saw Maxi river Mini river Wire river Svnthes rill Ansoack rill Zimmer Surqiairtome Stryker rill
5 EQUIPMENT CON'T Stryker/Zimmer Oscillating Saw Stryker Zimmer Reciorccatino vonics Intra-Articular Shaver yonics Advanced Arthroplasty Stryker Micro-electric Arthroplasty Midas Rex Cod man rill/perforator Giqli Saw 3M Craniotome 3M Air rill Ronialr AGE SPECIFIC PRACTICE Infants & Toddlers (ages 0-3 vrs) Young Children (4-6 yrs) Older Children (7-12 vrs) Adolescents (ages yrs) Young Adults (ages yrs) Middle Adults (ages yrs) Older Adults (ages yrs) Adults (ages> 80) The information I have given is true and accurate to the best of my knowledge. I hereby authorize Prime Staffing, LLC to release this Skills Checklist to client facilities of Prime Staffing, LLC in consideration for placement as a Traveler Nurse with those facilities. Signature Address Phone ate. ~
OPERATING ROOM SKILLS CHECKLIST
OPERATING ROOM SKILLS CHECKLIST Name: Registered Nurse Technician CTS When completing this ckecklist, please indicate your level of proficiency in each area according to the scale below. Place a check
OR Skills Checklist. Frequency Scale: 1 = Never Observed 2 = Less than 6 times a year 3 = 1 or 2 Times a Month 4 = Daily or Weekly
OR Skills Checklist This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application for employment
Orientation Procedure Check List
Orientation Check List Name: Preceptor(s): Place tally marks in proper boxes for each procedure. When orientee is competent in particular procedure then, date & initial next to procedure (both preceptor
Arteriovenostomy for renal dialysis 39.27, 39.42
Surgery categories NHSN Surgery codes (Reference: NHSN Operative Procedure Category Mappings to ICD-9-CM Codes, October 2010 www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf) Operative aortic aneurysm
INTERNATIONAL HEALTHCARE RECRUITERS
GENERAL SURGERY Scrub Circ. EQUIPMENT Scrub Circ. Hernias Breast Biopsies Perineal Resection Anal Fissurectomy Mastectomy Radical Mastectomy Bowel Resection Colostomy / Ileostomy Adreanalectomy Appendectomy
Pediatrics Skills Checklist
Pediatrics Skills Checklist This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application
Summary of Operative Experience
Summary of Operative Experience (Remarks: Programme Directors of respective Specialty Boards will conduct random check of the trainee s Logbook Summary and Logbook Summary Report against the operation
OUTPATIENT Surgery Estimates APPENDECTOMY-laparoscopic: $17, Open-none in 2018 in OPS setting OBS PTS (laparoscopic) $27,973.
OUTPATIENT Surgery Estimates 2019 APPENDECTOMY-laparoscopic: $17,852.53 Open-none in 2018 in OPS setting OBS PTS (laparoscopic) $27,973.96 BILATERAL TUBAL LIGATION Laparoscopic using clips: $17,193.28
SUMMARY OF OPERATIVE EXPERIENCE
RECORD NATURE OF CASES MAJOR PROCEDURES SUMMARY OF OPERATIVE EXPERIENCE Major Procedures Groups 1 & 2 ABDOMINAL OTHER Adrenalectomy open Laparotomy other - specify Major ventral hernia BREAST Breast reconstruction
Form C KNHSS Operative Procedure Categories Codes
Form C KNHSS Operative Procedure Categories Codes NHSN Operative Procedure Category Mappings to ICD-9-CM Codes and CPT Codes CPT codes are to be used for outpatient surgery cases only. KNHSS Code NHSN
TELEMETRY/STEPDOWN UNIT SKILLS CHECKLIST
TELEMETRY/STEPDOWN UNIT SKILLS CHECKLIST NAME: DATE: Please check the appropriate letter of proficiency for the following types of clinical situations and equipment. LEVEL OF PROFICIENCY A = Able to teach
Appendix Five Volume of practice and workplace-based assessment requirements for the specialised study units
Appendix Five and workplace-based assessment requirements for the specialised study units This appendix contains tables setting out both the volume of practice (VOP) and workplace-based assessment (WBA)
Service. Years of Experience: Directions for completing skills checklist:
Professional Nursing Service Name: Operating Room Checklist Date: Years of Experience: Directions for completing skills checklist: The following is a list of equipment and/or procedures performed in rendering
Service. Years of Experience: Directions for completing skills checklist:
Professional Nursing Service Name: Surgical Technician Checklist Date: Years of Experience: Directions for completing skills checklist: The following is a list of equipment and/or procedures performed
SUPPLEMENTAL DIGITAL CONTENT 2 : SURGERY SUBGROUPS DEFINITONS AND DISTRIBUTION
mortality 24h in ICU mortality 24h in ICU 1 SUPPLEMETAL DIGITAL COTET 2 : SURGERY SUBGROUPS DEFIITOS AD DISTRIBUTIO =2,717,902 GHM codes* Surgery description CARDIAC SURGERY 05C021 to 05C034 Cardiac valve(s)
OPERATING ROOM SKILLS CHECKLIST
OPERATING ROOM SKILLS CHECKLIST 1111 North 3rd Street Instructions: Please complete this checklist to enable us to match your skills and interests with available assignments. Place an "X" in the appropriate
Wooster Community Hospital
Wooster Community Hospital For more information call 1761 Beall Avenue, Wooster, OH 330.263.8158 Discounts Do Not Apply to Packaged s Below 25% discount if paid on the date of the hospital statement (approximately
ALKANTIS internal use only / version October 1, Surgery indications
Surgery indications Point of Care: Operating Room (O.R.) ALKANTIS makes possible to control Patient s Pain using a Drugfree sterile and dry cold therapy into the Operating Room ü You do not longer need
LIST OF CLINICAL PRIVILEGES CARDIOTHORACIC SURGERY
LIST OF CLINICAL PRIVILEGES CARDIOTHORACIC SURGERY AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102. PRINCIPAL PURPOSE: To define the scope and limits of practice for individual providers.
PATIENT CARE POLICY. B. Type & Screen: C. Type & Crossmatch: D. Override Orders:
PATIENT CARE POLICY Subject: PATIENT CARE ADMINISTRATION Title: MINIMUM SURGICAL BLOOD ORDER SCHEDULE 1 of 9 Revision of: 07/10/2007 Policy # NMH PC 05.0094 Version: 1.0 Effective Date: 04/29/2010 Removal
CRITICAL CARE/INTENSIVE CARE SKILLS CHECKLIST
CRITICAL CARE/INTENSIVE CARE SKILLS CHECKLIST NAME: DATE: Please check the appropriate letter of proficiency for the following types of clinical situations an equipment. MEDICATIONS Unit Dose Pouring from
New World Medical Tourism
Ankle New World Medical Tourism Achilles Repair 7 2 $ 9,805 Brostrum Ligament Reconstruction 6 2 $ 8,850 Arthroscopy Ankle 3 0 $ 6,865 Bilateral Knee Arthroscopy 4 1 $ 8,725 Distal Clavicle Excision 4
Selected Operative Procedure Categories for KNHSS SSI Surveillance
Selected Operative Procedure Categories for KNHSS SSI Surveillance Breast Surgery Excision of lesion or tissue of breast including radical, modified, or quadrant resection, lumpectomy, incisional biopsy,
University of Maryland Medical Center - Shock Trauma Center Delineation of Clinical Privileges Section of Trauma and Acute Emergency Surgery
University of Maryland Medical Center - Shock Trauma Center Delineation of Clinical Section of Trauma and Acute Emergency Surgery Type of Request: Initial Renewal Name: /Operative Procedures INTEGUMENTARY/BREAST
Policy/ Purpose: Definitions: (Definitions of acronyms or specialized terminology) Instructions:
Title: Surgical Procedure Scheduling After 2200 Hours by Central Processing Document #: 5962 Version: 1 Facility: St. Charles Bend Page 1 of 5 Owner: Roberts, Andrew,Manager Central Processing Effective
SURGERY CENTER SUMMARY OF SERVICES AND AVERAGE PRICING
SURGERY CENTER SUMMARY OF SERVICES AND AVERAGE PRICING Prices Include the Following: Facility, Surgeon, Anesthesia, immediate pre- and post-op care & surgical supplies. Implants, when applicable, are excluded,
Total NRS 0 NRS 1 NRS 2 NRS 3 NRS 4 NRS 5 NRS 6 NRS 7 NRS 8 NRS 9 NRS 10
Table 1: Frequencies of worst pain intensity scores (Numeric Rating Scale, NRS 0-10) of 179 surgical procedures. Frequencies of patients with pain intensities higher than NRS 6 and 8. Total 50199 3056
Stepdown Skills Checklist
Stepdown Skills Checklist This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application
AFL REVISION NOTICE. Please delete previous copies of this AFL and replace with the April 27, 2011 revised version.
State of California Health and Human Services Agency California Department of Public Health HOWARD BACKER, MD, MPH Interim Director EDMUND G. BROWN JR. Governor AFL REVISION NOTICE Subject: Requirements
Hilton Head ENT, Allergy, Sinus Hearing Center
Name: DOB: Page 1 of 6 ** *********************** Past Medical History ********************** Cancer: Bone Cancer: Brain Cancer: Breast Cancer: Cervical Cancer: Chronic Lymphocytic Leukemia Cancer: Colon
NATIONAL ELECTIVE SURGERY URGENCY CATEGORISATION
NATIONAL ELECTIVE SURGERY URGENCY CATEGORISATION GUIDELINE APRIL 2015 ACKNOWLEDGEMENTS The Australian Health Ministers Advisory Council (AHMAC) would like to acknowledge the contributions of a range of
Selected tables standardised to Segi population
Selected tables standardised to Segi population LIST OF TABLES Table 4.2S: Selected causes of death, all-ages, 2000 2004 (Segi Standard) Table 5.3S: Public hospitalisations by major cause of admission
NEONATAL INTENSIVE CARE SKILLS CHECKLIST
NEONATAL INTENSIVE CARE SKILLS CHECKLIST NAME: DATE: Please check the appropriate letter of proficiency for the following types of clinical situations and equipment. GENERAL Gestational assessment Physical
Surgical Privileges Form: Vascular Surgery
Surgical Form: Vascular Surgery Clinical Request Applicant s Name:. License No. (If Any):... Date:... Scope of Practice:. Facility:.. Place of Work:. CATEGORY I: GENERAL PRIVILEGES 1. Admitting privileges
Lymph: Anemia Cancer: Bone. Endocrine: Other. Lymph: Bleeding Cancer: Brain. General: Eating disorder. disorder/hemophilia Cancer: Breast
Medical History: Please check off any of the following medical conditions that you currently have: NONE Endocrine: Lymph: Anemia Cancer: Bone General: Eating disorder Lymph: Bleeding Cancer: Brain General:
TOTAL Head and Neck Congenital Defects 50
Operative Minimums Effective July 1, 2014 Review Committee for Plastic Surgery NOTE: The index procedure number for Laser is tracked by Total Laser and not by the subcategories of Aesthetic Laser and Reconstructive
Delineation Of Privileges Otolaryngology Privileges
Delineation Of s Otolaryngology s OTOLARYNGOLOGY PRIVILEGES Criteria - New Applicants: Board Certification or qualified for certification by the American Board of Otolaryngology. Criteria - Current Staff
Name: DOB: Sex: Male Female
Today s Date: Name: DOB: Sex: Male Female What doctor are you seeing today? Referring Physician s name and phone number: Primary Care Physician s name: Primary Care Physician s Phone Number: Reason for
ASPEN MEDICAL SURGERY REGINA
It is hereby certified that ASPEN MEDICAL SURGERY REGINA Has successfully completed an inspection as is required under the College s Bylaw 26.1 and is therefore approved as a Non Hospital Treatment Facility
Preferred Pharmacy. Past Medical History
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Phone Number (day): Phone Number (evening): Email Address: Emergency Contact: Preferred Pharmacy Name: Phone Number: City and
Delineation Of Privileges Otolaryngology Privileges
OTOLARYNGOLOGY PRIVILEGES Criteria - New Applicants: Board Certification or qualified for certification by the American Board of Otolaryngology. Criteria - Current Staff Members Only: Successful completion
WELSH INFORMATION GOVERNANCE & STANDARDS BOARD
WELSH INFORMATION GOVERNANCE & STANDARDS BOARD DSC Notice: Date of Issue: 2 nd June 2010 Ministerial / Official Letter: EH/ML/041/09 Subject: NHS Wales Short Stay Surgery Basket of Procedures Sponsor:
DIAGNOSTIC PROCEDURE BENEFIT RIDER
DIAGNOSTIC PROCEDURE BENEFIT RIDER We will pay the benefit amount indicated on the Policy Schedule when any covered person incurs charges for and has one of the following diagnostic procedures while this
Division: Medical Management Department: Utilization Management
Retired Date: Page 1 of 1 1. POLICY DESCRIPTION: Gender Reassignment Surgery 2. RESPONSIBLE PARTIES: Medical Management Administration, Utilization Management, Integrated Care Management, Pharmacy, Claims
A neonate is any patient less than 45 weeks post conception regardless of chronological age.
Case Log Definitions: A Guide for Fellows and Program Directors Recommendations from the Pediatric Anesthesia Program Directors Association Case Log Task Force January 2013 These recommendations represent
Chapter 13 Worksheet Code It
Class: Date: Chapter 13 Worksheet 3 2 1 Code It True/False Indicate whether the statement is true or false. 1. A cardiac catheterization diverts blood from the heart to the aorta. 2. Selective vascular
DEPARTMENT OF SURGERY DELINEATION OF PRIVILEGES FOR GENERAL SURGERY
DEPARTMENT OF SURGERY DELINEATION OF PRIVILEGES FOR GENERAL SURGERY NAME: DATE: Please check the box for each privilege requested. Applicants have the burden of producing information deemed adequate by
INDIANA HEALTH COVERAGE PROGRAMS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables
LIST OF CLINICAL PRIVILEGES PEDIATRIC SURGERY
AUTHORITY: Title 10, U.S.C. Chapter 55, Sections 1094 and 1102. PRINCIPAL PURPOSE: To define the scope and limits of practice for individual providers. Privileges are based on evaluation of the individual
Surgical Training for Austere Environments
Surgical Training for Austere Environments Programme Course Director: Mr Vascular and Trauma Surgeon, St Marys Hospital, London Acknowledgements The Royal College of Surgeons of England is a charitable
Arkansas State Specific UM Statistics for Prior Authorizations
Arkansas State Specific UM Statistics for Prior Authorizations 2016 2017 Quarter One Quarter Two Quarter Three Quarter Four 2018 Quarter One Quarter Two Quarter Three Quarter Four 2016 Number of Prior
Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU.
Name Date of Birth PLEASE COMPLETE ALL PAGES AND ITEMS -- THANK YOU. Past Medical History Select any of the following medical conditions that you currently have Adrenal Insufficiency Anemia/Thalassemia
College of Southern Idaho Surgical First Assisting Program Perioperative (scrub) Skills checklist
College of Southern Idaho Surgical First Assisting Program Perioperative (scrub) Skills checklist Full name (please type or print) (date) Instructions: Please check the appropriate column that best describes
Oregon CPT Preapproval Grid
Not Applicable Home Health Stays - For all Initial Certification and Recertification periods Notes: Initial Certification review required effective 1/1/12. Not Applicable Skilled Nursing Facility Stays
Patient Interview Form
Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one
Health History Questionnaire
Health History Questionnaire Page 1 of 8 Thank you for choosing Martin s Point to be your partner in health. To help us give you the highest-quality care, please answer the questions on this form as well
Prior Authorization List Effective February 2, 2015
Prior Authorization List Effective February 2, 2015 Prior authorization is required for the following services. Prior authorization is the responsibility of the provider ordering or rendering services
DEPARTMENT OF SURGERY CARDIOVASCULAR-THORACIC SECTION
DEPARTMENT OF SURGERY CARDIOVASCULAR-THORACIC SECTION DIRECTIONS: This must accompany all initial applications for appointment to the Cardiovascular-Thoracic Section, Department of Surgery. Please indicate
Instructional/Task Analysis
Anatomy Surgical and Procedures Physiology Module 1: General Surgery 2. Primary purposes of general 3. Common diagnostic tests and used prior to or during general 4. Relevant anatomy groups for general
NOACS/DOACS*: PERI-OPERATIVE MANAGEMENT
NOACS/DOACS*: PERI-OPERATIVE MANAGEMENT OBJECTIVE: To provide guidance for the peri-operative management of patients who are receiving a newer direct oral anticoagulant (DOAC) and require an elective surgery/procedure.
Evidence-Based Postoperative Opioid Prescribing Guidelines
Evidence-Based Postoperative Opioid Prescribing Guidelines PA NSQIP Consortium October 18, 2018 Thomas Farley, MD, MPH Commissioner Philadelphia Department of Public Health Evidence-Based Postoperative
Steven J. Smith Kingwood Dr., BLDG. 6 Kingwood, Texas 77339
97 Kingwood Dr., BLDG. 6 Kingwood, Texas 779 MEDICAL HISTORY (please print) LAST NAME FIRST NAME M F DOB REASON FOR VISIT MEDICATIONS Please list all the medications you are currently taking, including
Jan 30, Dear Provider:
Jan 30, 2015 Dear Provider: Kern Health Systems strives to provide quality and timely services to our members. Recently, KHS made changes to the services included on Prior Authorization Needed list. The
SCOPE OF PRACTICE PGY-6 PGY-7 PGY-8
PGY-6 Round on all plastic surgery inpatients every day. Assess progress of patients and identify real or potential problems. Review patients progress with attending physicians daily and participate in
WARFARIN: PERI OPERATIVE MANAGEMENT
WARFARIN: PERI OPERATIVE MANAGEMENT OBJECTIVE: To provide an approach to the perioperative management of warfarin treated patients who require an elective or urgent surgery/procedure. To provide an approach
ต วอย าง AF เคร องม อทางการแพทย ท จะศ กษาท ม ความเส ยงน อยและความเส ยงมาก
EXAMPLES: ต วอย าง เคร องม อทางการแพทย ท จะศ กษาท ม ความเส ยงน อยและความเส ยงมาก ต วอย างเคร องม อทางการแพทย ท จะศ กษาท ม ความเส ยงน อย NON-SIGNIFICANT RISK DEVICE STUDIES Bio-stimulation Lasers for treatment
Patient Name: Date of Birth:
Patient Name: Date of Birth: Marital Status: Single Married Divorced Widowed Height: Referring Doctor: Weight: Primary Care Dr.: Preferred Pharmacy:(name/address) ALLERGIES: Do you have any drug allergies?
SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY
PS1070 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: ADMISSION/DISCHARGE CRITERIA: CARDIOVASCULAR INTENSIVE Job Title of Reviewer: Director, CVICU EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY
Patient Name: Date of Birth: Preferred Pharmacy: (name/location/phone #)
Patient Name: Date of Birth: Referring Doctor: Primary Care Dr: Preferred Pharmacy: (name/location/phone #) CURRENT MEDICATIONS: Please list all Medication Dose Frequency 1 2 3 4 5 6 7 8 9 10 11 12 13
MAJOR SURGICAL BENEFIT ANNEXURE. Sl. No. LIST OF MAJOR SURGERIES Major Surgical Benefit Sum Assured
MAJOR SURGICAL BENEFIT ANNEXURE Sl. No. LIST OF MAJOR SURGERIES I CARDIOVASCULAR SYSTEM 1 Surgery of Aorta 100% 1 2 CABG (two or more coronary arteries must be bypassed) 100% 1 via open chest surgery 3
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
ARTHRITIS & RHEUMATOLOGY OF GA, PC
ARTHRITIS & RHEUMATOLOGY OF GA, PC GARY MYERSON, MD PAUL SUTEJ, MD PAULA TANASA, MD ANNA ADAMS, PA-C CASHELLE ROSE, PA-C NEW PATIENT REGISTRATION FORM (Please Print) Patient Information Patient s last
CY2015 Hospital Outpatient: Endovascular Procedure APCs and Complexity Adjustments
CY2015 Hospital Outpatient: Endovascular Procedure APCs Complexity Adjustments Comprehensive Ambulatory Payment Classifications (c-apcs) CMS finalized the implementation of 25 Comprehensive APC to further
INSTRUCTIONS. #2 = Competent and familiar with procedure: I can perform this procedure with excellence, usually without assistance.
PERIOPERATIVE SKILLS CHECKLIST Date: Full Name: INSTRUCTIONS Please provide accurate answers so we can correctly match your abilities to our client job requirements. Please check the level of experience
Wooster Community Hospital Package Pricing
Wooster Community Hospital 2O18 Self- Pay Package Pricing AWARD WINNING H O S P I T A L Wooster Community Hospital Discounts Do Not Apply to Packaged Prices Below 25% discount if paid on the date of the
REDDING ANATOMIC PATHOLOGY SURGICAL PATHOLOGY SPECIMEN COLLECTION
REDDING ANATOMIC PATHOLOGY SURGICAL PATHOLOGY SPECIMEN COLLECTION I. PRINCIPLE: Most, but not all, tissues and foreign objects removed surgically should be examined by a Pathologist, in order to ensure
2019 Self-Pay Package Pricing
2019 Self-Pay Package Pricing Wooster Community Hospital The package prices are discounted in exchange for prompt payment, the day of service. Discounts Do Not Apply to Packaged Prices Below 25% discount
Department of Otolaryngology Clinical Privileges
Department of Otolaryngology Clinical Privileges Name: To be completed by Medical Staff Office: Effective from: Check one: Initial Privileges (appointment) Renewal of Privileges (reappointment) to: Applicant:
The Adolescent and Adult Congenital Heart Disease Program
The Adolescent and Adult Congenital Heart Disease Program The Heart Center at Nationwide Children s Hospital & The Ohio State University D- Transposition of the Great Vessels D- transposition of the great
Loma Linda University Children s Hospital Loma Linda, CA PLASTIC AND RECONSTRUCTIVE SURGERY PRIVILEGE FORM
Name: Page 1 of 6 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All
Old Procedure Name* New Procedure Name* Core* Comment* Standardize*
_OTHER/unlisted (see comment) _OTHER/unlisted (see comment) X No change No ACL repair, arthroscopic ACL repair, arthroscopic X No change No ACLS protocol (CPR, Code Blue) ACLS A1 Renamed Yes Amniocentesis
University of Florida Department of Surgery. CardioThoracic Surgery VA Learning Objectives
University of Florida Department of Surgery CardioThoracic Surgery VA Learning Objectives This service performs coronary revascularization, valve replacement and lung cancer resections. There are 2 faculty
FROST FAMILY MEDICINE
Patient Information (Please Sign and return to Receptionist) Home Phone Day Phone Cell Phone E-mail Driver s License # Preferred Language Race Soc Sec # Gender: Male Female Marital Status: Single Married
Loma Linda University Medical Center Loma Linda, CA 92354
Name: Page 1 of 6 REQUEST CATEGORY MEMBERSHIP CATEGORY Provisional (Bylaws 4.3) Administrative (Bylaws 4.7) Affiliate (Bylaws(4.9) Active (Bylaws 4.2) Courtesy (Bylaws 4.4) Consulting (Bylaws 4.5) All
Biopsy, CT Scan/ MRI. CT, ERCP, CA 19-9, PET Scan, EUS. Biopsy, CT, IVP, KUB,USG. Biopsy, CT, IVP, KUB,USG. Biopsy, CT, IVP, KUB,USG
Package no Sub speciality 11.2 Throat 11.3 Throat Procedure name Microlaryngeal Surgery including Phonosurgery Excision/ Hypopharynx of Tumors in Pharynx SURGICAL ONCOLOGY Pre-Operative Post Operative
Wooster Community Hospital
Package Pricing Wooster Community Hospital For more information call 1761 Beall Avenue, Wooster, OH 330.263.8158 Discounts Do Not Apply to Packaged s Below 25% discount if paid on the date of the hospital
Intake and History Form
Name: Date: Street Address: City / State: Zip Code: Date of Birth: Gender: Soc. Sec. #: Phone Number (day): Phone Number (day): Email Address: Emergency Contact: # Preferred Language: _ Race: Ethnic Group:
ER Skills Checklist. Frequency Scale: 1 = Never Observed 2 = Less than 6 times a year 3 = 1 or 2 Times a Month 4 = Daily or Weekly
ER Skills Checklist This assessment is for determining your experience in the below outlined clinical areas. This checklist will not be used as a determining factor in accepting your application for employment
Wooster. Community. Hospital. Far Ahead...Close to Home AWARD WINNING
Wooster Community Hospital S E L F - PA Y PAC K AG E P R I C I N G Far Ahead...Close to Home AWARD WINNING H O S P I T A L Wooster Community Hospital Discounts Do Not Apply to Packaged Prices Below 25%
Patient Intake Form. Male Female Employment Status Employer Employer Address Employed
Thank you for choosing Community Hospital-Fairfax Family Medicine Clinics. We are delighted to provide your care. If you are a patient of the Rock Port, Tarkio or Fairfax Clinics, please complete this
Notification of changes to AXA PPP Schedule of Procedures & Fees March 2018
Call our Specialist Fees Team 01892 772160 Mon-Fri 9am-1pm specialistfees@axa-ppp.co.uk We may record and monitor calls for quality assurance, training and as a record of our conversation.. Notification
Delineation Of Privileges Vascular Surgery Privileges
CATEGORY 1 - VASCULAR SURGERY PRIVILEGES Criteria: New Applicants must meet one of the following: a) Board Certification or qualified for certification by the American Board of Vascular Surgery; b) Completion
IMA NHB Suggested Package amount for negotiation with Insurance Companies
IMA NHB Suggested Package amount for negotiation with Insurance Companies S.No Name of the Procedure -Treatment System IMA MHB Proposed minimum quotable rate for single room non A/c 1 CABG CARDIOLOGY 2
20 HOSPITAL S 17 TANDARD
2017 This hospital plan offers extensive hospital benefits with some value-added benefits. Unlimited cover up to 100% in hospital 27 PMB chronic conditions covered Network specialists paid in full in hospital
Morbidity Audit and Logbook Tool SNOMED Board Reporting Terms for SET and IMG Vascular Surgery AMPUTATION AORTA
SNOMED s for SET and IMG Vascular Surgery AMPUTATION Amputation above-knee Amputation of leg through tibia and fibula Amputation of the foot Amputation of toe Through knee amputation Ray amputation of
99202 Office visit new patient, problem expanded $ Smoking and tobacco use cessation counseling visit $37.30
MILBRIDGE MEDICAL CENTER FAMILY PRACTICE 24 SCHOOL ST, MILBRIDGE ME 99202 Office visit new patient, problem expanded $140.90 99406 Smoking and tobacco use cessation counseling visit $37.30 99397 Preventive
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM Reason for visit: Previous and/or Maiden Name: Parent/Guardian Name if patient is minor: Birth date: (M/D/Yr) Gender: Male Female SSN (patient): SSN (guardian, if patient is minor):
20 BON ESS 17 ENTIAL
2017 This hospital plan offers rich hospital benefits with some value-added benefits. Unlimited cover up to 100% in hospital 27 PMB chronic conditions covered Network specialists paid in full in hospital
For Reference Only GENERAL SURGERY 2013
Summary of Services and Availability (by location) Each location has sufficient space, equipment, staffing and financial resources in place or available in sufficient time as required to support each requested