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Albuquerque Service Unit: Medical Record

• Prenatal and Pregnancy Flowsheet - Albuquerque Service Unit: Medical Record
  • Page 1 [WORD 98k] • Page 2 [WORD 57k]

Alcohol Withdrawal Assessment Sheets (PIMC Apr 05) [WORD 140k]

Alcohol Withdrawal Protocol (PIMC Apr 05) [WORD 55k]

Asthma card - child care, Allergy and Asthma Foundation of America

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BTL form (bilateral tubal ligation) [PDF 331k]

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PCC Comprehensive Elder Exam (IHS 865) [PDF 643k]

Credentialing and Privileging Guide, IHS, Revised 9/05 [PDF 999k]

Consent Forms

• Arthrocentesis Consent (WR) [PDF 315k]
• Blood Transfusion Consent (WR) [PDF 315k]
• Central Line Consent (WR) [PDF 317k]
• Contrast Intravenous Consent Form (WR) [WORD 26k]
• Infliximab & Etanercept Consent (WR) [PDF 309k]
• Sterilization (male and female) [PDF 331k]

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Domestic Violence

• Prenatal assessment: ETOH, substances, Domestic Violence [PDF 24k]

Diabetes in pregnancy checklist [WORD 53k]

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Elder Exam PCC Comprehensive (IHS 865) [PDF 643k]

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Hypertension in pregnancy checklist [WORD 49k]

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Insulin Sliding Scale Inpatient

• Insulin Sliding Scale Inpatient Form (WR) [WORD 52k]
• SSI MAR Agressive (WR) [WORD 131k]
• SSI MAR Back (WR) [WORD 88k]
• SSI MAR Custom (WR) [WORD 155k]
• SSI MAR Mild (WR) [WORD 131k]
• SSI MAR Mod (WR) [WORD 132k]

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Elder Exam PCC Comprehensive (IHS 865) [PDF 643k]

PCC+ Forms for Women's Health and Prenatal Care
Please note: the Word documents are all about 160k and the PDF's are about 50k.

Colposcopy PCC+ form:	Word       PDF
Did not keep appointment (DNKA):	Word PDF
Family Planning:	Word       PDF
Gynecology:	Word       PDF
Gynecology Comprehensive:	Word PDF
Gynecology Walk-in:	Word PDF
Labor & Delivery:	Word       PDF
L / D Triage (ANMC):	Word       PDF
Midwifery:	Word       PDF
OB/GYN Call-in/Phone:	Word       PDF
OB/GYN Walk-in:	Word       PDF
OB Revisit:	Word       PDF
OB Walk-in:	Word       PDF
Postpartum:	Word       PDF
Prenatal Revisit No. 2:	Word PDF
Prenatal flow sheet, ANMC:	Word PDF
Tobacco cessation, Cherokee:	Word
Tobacco Cessation Chart form: Five A's:	PDF [18k]
Well Women's Exam:	Word

PCC+ Web Page, Many Templates Available

Pneumonia Admission Orders (PIMC) [WORD 38k]

Prenatal and Pregnancy Flowsheet - Albuquerque Service Unit: Medical Record

• Page 1 [WORD 98k] • Page 2 [WORD 57k]

Prenatal assessment: ETOH, Substances, Domestic Violence [PDF 24k]

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Sterilization Consent (30 day form) [PDF 331k]

Substance Abuse

• Prenatal assessment: ETOH, Substances, Domestic Violence [PDF 24k]
• Tobacco Cessation Chart Form: Five A's
  • Ask, Advise, Assess, Assist, Arrange [PDF 18k]
• Tobacco Cessation, Cherokee

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Tobacco Cessation Chart Form: Five A's

• Ask, Advise, Assess, Assist, Arrange [PDF 18k]

Tobacco Cessation, Cherokee

Trial of Labor After Cesarean

• VBAC and TOLAC Consent Forms
  • University of New Mexico: TOLAC consent [WORD 24k]
  • Vermont/New Hampshire VBAC Project: Consent for Birth After Cesarean [PDF]

Tubal ligation Consent (30 day form) [PDF 331k]

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VBAC and TOLAC Consent Forms

• University of New Mexico: TOLAC consent [WORD 24k]
• Vermont/New Hampshire VBAC Project: Consent for Birth After Cesarean [PDF]

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Please note, regarding the material described above:

• The material presented is meant to further your local discussion of best practices. It is not meant to provide a template for care. Please share it with your local clinical staff and alter to fit your local needs
• Material for each topic on these sites has been developed by other providers based on that person's clinical judgment and experience as an expert in that field
• The material does not represent official policy or recommendations of the Indian Health Service or the other agencies involved
• Its publication should not be construed as excluding other acceptable methods of handling similar problems
• Please let the site coordinator know if you have questions or concerns about any of the material. Thanks