- Facesheet
- Infirmary Daily Shift Assessment - RN
- Infirmary Shift Note - LPN
- Medical Lay-In/Restrictions
- Medical Progress Note - NARRATIVE (Same as progress note 140106B)
- Medical Progress Note - SOAP (Same as progress note 140106B)
- Mental Health Evaluation for Lower Security
- Mental Health Intake Record Review
- Mental Health Progress Note Narrative (Same as progress note 140106B)
- Mental Health Progress Note SOAP (Same as progress note 140106B)
- Mental Health Provider Note
- Notification of Hospital Admission to Local Hospital
- Offender Discipline Recommendations
- Optometric Progress Note - Narrative
- Providers Infirmary Admission Assessment
- Providers Infirmary Assessment Note
- Psychopharmacological Medication Screening and Management
- Periodic Physical Examination (Non-Chronic Clinic)
- Segregated Housing Unit (SHU) Medical Record Review
- Telepsychiatry/Psychiatry Note
Healthcare Records
Table of Contents MSRM 140106.01
In the event that the EHR is not operational, a paper format system will be used. Healthcare record forms for services normally documented in the EHR, will be available at each facility for staff use.
The following forms are available electronically for use.
- Chronic Clinic Note - Physical Exam (DOC140137A)
- Chronic Clinic RN Progress Note (MSRM 140137.09)
- Chronic Illness Management Guidelines Routine and Annual Treatment Guidelines (OP140137b)
- Medical Diet Request (DOC 070202A)
- Severity Classification of Common Chronic Illness (OP140137a)
- Airborne Infection Isolation Room Checklist (DOC 140301A)
- Aminoglycosides (MSRM 140301.04C)
- Annual TB Summary Form (MSRM 140301.04F)
- Bloodborne Pathogen Exposure Follow-up Instructions (MSRM 140125.02H)
- Bloodborne Pathogen Exposure Report (MSRM 140125.02A)
- Clofazimine (MSRM 140301.04D)
- Concentric Circles (MSRM 140301.02A)
- Contact Investigation-Acute Hepatitis A (MSRM 140125.01A)
- Contact Investigation-Acute Hepatitis B (MSRM 140125.01B)
- Cycloserine (CS) (MSRM 140301.04E)
- Decontamination Handbook for Bloodborne Pathogens (MSRM 140125.02A)
- Disaster Triage Guidelines-Pandemic Influenza (MSRM 140118.02B)
- Ethambutol (EMB) (MSRM 140301.4F)
- Ethionamide (ETA) (MSRM 140301.4G)
- Fluoroquinolones (MSRM 140301.04H)
- Hepatitis B Algorithm (MSRM 140125.02B)
- Hepatitis B Immune Globulin Information Sheet (British Columbia Ministry of Health) (MSRM 140125.02D)
- Hepatitis B Vaccine Declination Form (DOC 140125C)
- HIV Exposure Prophylaxis Guidelines (MSRM 140125.02J)
- HIV Offender Roster Review Log (DOC 140125B)
- HIV Postexposure Prophylaxis Consent Form (MSRM 140125.02I)
- ILI Assessment Tool (MSRM 140118.02C)
- Information Sheet: When you are considering PEP (MSRM 140125.02G)
- Isoniazid(INH) (MSRM 140301.4I)
- Mass Prophylaxis Plan (MSRM 140118.02 Attachment A)
- Mass Prophylaxis Triage Checklist (MSRM 140118.02F)
- Memorandum of Understanding (MSRM 140118.02D)
- Oseltamivir (Tamiflu) Information (MSRM 140118.02G)
- p-Aminosalicylic Acid (PAS) (MSRM 140301.04J)
- Pandemic Surveillance Tracking Sheet (MSRM 140118.02A)
- Post-Mortem Checklist (MSRM 140118.02E)
- Preventive Therapy Waiver for Tuberculosis Infection (OP140301e)
- Pyrazinamide (PZA) (MSRM 140301.04K)
- Rainbow Passage (MSRM 140301.01aa)
- Report of Injury or Unusual Occurrence/Encounter (DOC 140125A)
- Respirator Questionnaire (MSRM 140301.01A)
- Rifabutin (MSRM 140301.04L)
- Rifampin (RMP) (MSRM 140301.04M)
- Sputum Collection (DOC 140301A)
- TB Contact Investigation Form (MSRM 140301.02A)
- TB Contact Investigation Worksheet (MSRM 140301.02B)
- TB Medications Lab Work (MSRM 140301.04B)
- TB Medications Monitoring (MSRM 140301.04aa)
- TB Monthly Monitoring (MSRM 140301.04A)
- TST Interpretation Form (MSRM 140301.03A)
- Tuberculosis and Immunization History Record (DOC 140301B)
- Tuberculosis Medication Charting (DOC 140301G)
- Tuberculosis Summary Record (DOC 140301C)
- Vaccine Administration Consent Form (DOC 140701B)
- Vaccine Administration Consent Form - Hep B (MSRM 140125.02F)
- Basic Initial/Annual RN Competency Verification (MSRM 140143.01A)
- Basic Initial/Annual LPN Competency Verification (MSRM 140143.01B)
- Basic Initial/Annual CMA Competency Verification (MSRM 140143.01C)
- Basic Initial/Annual MHU Competency Verification (MSRM 140143.01D)
- Basic Initial/Annual OB-GYN Competency Verification (MSRM 140143.E)
- Consent for Medical, Dental and Mental Health Treatment (DOC 140701A)
- Fecal Occult Testing Education/Acceptance/Waiver (DOC 140117C)
- Neuroleptic's Informed Consent (DOC 140701C)
- Orthoses, Prostheses, and Other Aids of Impairment Appliance Record (DOC 140133A)
- Vaccine Administration Consent Form (DOC 140701B)
- Waiver of Treatment (OP140117d)
- Dental Initial Exam (MSRM 140124A)
- Dental Plaque Index (MSRM 140124B)
- Dental Treatment Plan (MSRM 140124C)
- Endodontic and Orthodontic Consent (DOC 140124F)
- Periodontal Charting (DOC 140124D)
- Request for Dental Exception (DOC 140124G)
- Review of Partial Dentures (DOC 140124E)
- Case Manager Review/Medical Treatment Evaluation (MSRM 140137.06A)
- Hepatitis C Frequently Asked Questions (MSRM 140137.06B)
- Waiver of Treatment for Hepatitis C (MSRM 140137.06C)
- Hepatitis C Agreement for Treatment Work-Up (MSRM 140137.06D)
- TeleHepatology (MSRM 140136.06E)
- HCV Post Treatment Note (MSRM 140137.06F)
- HCV Treatment Work-Up Provider Note (MSRM 140137.06G)
- HCV Medication Regimen and Documentation (MSRM 140137.06H)
- Infirmary Discharge Summary (OP140119c)
- Infirmary Health Care Plan (OP140119b)
- Vital Sign Test Monitoring Record (Contact Judy Brinkley for form)
- Do Not Resuscitate Consent Form (OP140138c)
- Living Will/Advance Directive for Health Care (OP140138a)
- Notice of Activation, For Living Will/Advanced Directive and/or DNR (OP140138b)
- Optometric Service Record (OP140132c)
- Radiographic Report (OP140132b)
- Refrigerator Temperature Log (OP140132a)
- Activity Housing Summary (IHAP) (OP140113c)
- Discharge Health Summary (OP140106d)
- Food Service Work Permission Slip (OP140106e)
- Initial and Routine Physical Exam (OP140114c)
- Intra-System Transfer Health Screening (OP140113b)
- Medical Transfer Request (OP140113e)
- Medical Transfer Summary (OP140113a)
- Medical/Mental Health Screening (OP140114a)
- Mental Health Transfer Request (OP140113f)
- Monthly Report Worksheet (OP140107a)
- Orthoses, Prostheses, and Other Aids of Impairment Appliance Record (OP140133a)
- Physician Orders (OP140106f)
- Problem List (OP140106a)
- Progress Note (OP140106b)
- Request for Health Services (OP140117a)
- Sick Call Log (OP140117b)
- (AIMS) Abnormal Involuntary Movement Scale Facial and Oral Movement (Same as Abnormal Involuntary Movement Scale) (OP140201c)
- Authorization For Application of Therapeutic Five Point Restraints (OP140141a)
- Certification Checklist for Safe/Therapeutic Seclusion/Restraint Cell (OP140141d)
- Classification Level Log (MSRM 140201.01.4)
- Evaluation Summary (Explanation For Not Being Admitted to the Mental Health Unit) (OP1410127b)
- Facility Needs Assessment and Strategic Plan Format (OP140201d)
- Group Administered Mental Health Questionnaire Self Report Assessment (MSRM 140201.01.1)
- Involuntary Medication Appeal Decision (OP140652f)
- Involuntary Medication Appeal Request (OP140652e)
- Involuntary Medication Hearing Staff Representative Fact (OP140652d)
- Involuntary Medication Report (OP140652a)
- Level I Mental Health Screening Interview (Not Available for Public Access)
- Medication Review Committee Report (OP140652c)
- Mental Health Administration and Organization (140140aa)
- Mental Health Assessment for Restrictive Housing (OP140201b)
- Mental Health History and Psychosocial Assessment (Level II Screening Interview) (Not Available for Public Access)
- Mental Health or Mental Status Review (OP140201a)
- Mental Health Service Levels Classification System Criteria (OP140201ab)
- Mental Health Unit (MHU), Intermediate Care, Housing Unit (ICHU) or Habilitation Program (HP) Referral Form (OP140127a)
- Mental Health Unit Intake Form (OP140127c)
- Notice of Hearing to Consider Recommendation of Involuntary Administration of Psychotropic Medication (OP140652b)
- Physical Restraint Log (OP140141c)
- Procedures for Mental Health Four/Five Point Restraints (OP140141aa)
- Psychological Autopsy (OP140129aa)
- Restraint Medical Flow Sheet (OP140141b)
- Risk Management Interview Worksheet (OP1410129b)
- Suicide Watch List (OP140129c)
- Suicide Watch Conditions/Precautions (OP140129d)
- Suicide Watch Log (OP140129a)
- Therapeutic Seclusion Conditions/Precautions (OP140141f)
- Therapeutic Seclusion Watch Log (OP1410141e)
- Antepartum Record (MSRM 140145.01A)
- Care of Pregnant Inmate (MSRM 140145.01B)
- Diagnostic/Laboratory/X-ray Results - Offender Notification (MSRM 140145.01C)
- OB Information Sheet (MSRM 140145.01D)
- OB Registration Information Sheet (MSRM 140145.01E)
- PIH/Pre-eclampsia Flow Sheet (MSRM 140145.01F)
- Postpartum Lay-In Activity Status (MSRM 140145.01G)
- Pregnant Inmate Guidelines (MSRM 140145.01H)
- Authorization for Cremation and Disposition (DOC 140111B)
- Certificate of Death Information Report (DOC 140111C)
- Offender Death Report (DOC 140111A)
- Affidavit of Financial Responsibility for Medical, Mental Health, Dental and/or Vision Care (DOC 140121D)
- Health Care Leave Request Form (DOC 140121B)
- Outside Referral Record (DOC 140121A)
- Record of Treatment by Community Health Care Provider (DOC 1410121E)
- Rules for Health Care Leave and Medication for Offenders Assigned to Community Corrections (DOC 1410211C)
- Consent for Palliative Care (140146AD)
- Edmonton Symptom Assessment Graph (140146AA)
- Edmonton Symptom Assessment System Numerical Scale (140146AB)
- Offender Assistant Curriculum (MSRM 140146.01B)
- Offender Volunteer Agreement (140146AC)
- Palliative Care Progress Note and Checklist (MSRM 140146.02A)
- Patient Confidentiality Acknowledgement (MSRM 140146.01A)
- Providers Peer Review Criteria (140142AA)
- Qualified Mental Health Professional Peer Review Criteria (140142AB)
- Approved Canteen OTC Drugs (140130aa)
- Barcode Medication Refill Form (140130l)
- Community Corrections Supervised Medication/Syringe Count Log (140130j)
- Controlled Drug Prescription Form (140130f)
- Controlled Drug Stock Order Form - Schedule III-V Only (140130g)
- KOP vs. Pill Line B Security Level (140130ac)
- Medication Error Reporting Form (140130h)
- Medication Refill Slip (140130m)
- Monthly Stock Inventory Form (140130c)
- Non-Formulary Medication Request Form (140130d)
- ODOC Canteen OTC Drug Order Form (140130ab)
- Oklahoma DOC Practitioner Cards Form (140130b)
- Pharmaceutical Return Sheet (140130e)
- Stock Order Form (140130a)
- Suspected Adverse Drug Reaction (ADR) Reporting Form (140130k)
- Accounting of Disclosure Form (OP140108h)
- Acknowledgement of Request for Protected Health Information (OP140108i)
- Authorization for Disclosure of Protected Health Information, Release of Psychiatric/Psychological Records (OP140108g)
- Authorization for Release of PHI (OP140108a)
- Request for Corrections/Amendment of Protected Health History (OP140108j)
Last Modified on
Oct 02, 2024
