Section 14
OP-140106
- DOC 140106 A "ODOC Problem List"
- DOC 140106 B "ODOC Progress Note"
- DOC 140106 C "ODOC Medication Administration Record"
- DOC 140106 D "ODOC Discharge Health Summary"
- DOC 140106 E "ODOC Food Services Work Permission Slip"
- DOC 140106 F "ODOC Health Care Provider Orders"
OP-140107
- DOC 140107 A "Worksheet for Monthly Medical Activity Report"
OP-140108
- DOC 140108 A "Authorization for Release of Protected Health Information"
- DOC 140108 B "Revocation of Authorization for Release of Protected Health Information"
- DOC 140108 H "Accounting Of Disclosure Form"
- DOC 140108 I "Acknowledgement of Request for Protected Health Information"
- DOC 140108 J "Request for Correction/Amendment of Protected Health Information"
OP-140111
- DOC 140111A "Inmate Death Report"
- DOC 140111 B "Authorization for Cremation and Disposition"
- DOC 140111 C "ODOC Certificate of Death Information Report"
OP-140112
DOC 140112A “Glucometer Quality Control Record”
DOC 140112B “Monthly Oxygen Tank Inspection Log”
OP-140113
- DOC 140113A "Medical Transfer Summary"
- DOC 140113B "Intra-System Transfer Health Screening"
- DOC 140113C "Individual Health Activity Profile (IHAP)"
- DOC 140113E "Medical Transfer Request'
- DOC 140113F "Mental Health Transfer Request"
- DOC 140113G "Mental Health Recommendations for Lower Security"
- Attachment A "IHAP Facility Recommendation Decision Matrix"
- Attachment B "Medical Acuity Reference Guide"
- Attachment C "Specialized Medial Units/Beds"
OP-140114
- DOC 140114A "Medical/Mental Health Screening"
- DOC 140114C "Initial Intake and Routine Physical Examination"
- Attachment A "Initial Physical Examination and Laboratory Requirements: Male"
- Attachment B "Initial Physical Examination and Laboratory Requirements: Female"
OP-140115
- Attachment A "Periodic Physical Examination and Laboratory Requirements Male and Physical Examination and Laboratory Requirements for Inmates Returning from GPS Males"
- Attachment B "Periodic Physical Examination and Laboratory Requirements Female and Physical Examination and Laboratory Requirements for Inmates Returning from GPS Females"
OP-140116
- DOC 140116 A "Employee Medical Screening Form"
- DOC 140116 B "Medical Clearance for Respirator Use"
- OSHA Respirator Medical Evaluation Questionnaire
OP-140117
- DOC 140117 A "Request for Medical Services"
- DOC 140117 B "Sick Call Log"
- DOC 140117 C "Fecal Occult Blood Testing Education/Acceptance Waiver"
- DOC 140117 D "Waiver of Treatment"
- DOC 140117 E "Agreement to Attend Outside Specialty Appointment"
- Attachment A "Medications Exempted from $4.00 per Medication Co-Pay "
- Attachment B "Medical Orientation"
- Attachment B-1 "Medical Orientation" (Spanish)
OP-140118
- DOC 140118A "Daily/Monthly AED/Narcan Inspection Log"
- Attachment A "Non-Medical Facility Staff Administration and Access to Naloxone (Narcan)"
- Attachment B "Probation and Parole Officer (PPO) and Office of Inspector General (OIG) Agent Administration and Access to Naloxone (Narcan)"
OP-140119
- DOC 140119A "Infirmary Log"
- DOC 140119B "Infirmary Health Care Plan"
- DOC 140119C "Infirmary Discharge Summary"
- DOC 140119D "Infirmary/Convalescent H & P Admission Assessment"
- Attachment A "Infirmary Checklist"
OP-140121
- DOC 140121 A "Outside Referral Record Summary"
- DOC 140121 B "Health Care Leave Request"
- DOC 140121 C "Rules for Health Care Leave and Medication for Inmates Assigned to Community Corrections"
- DOC 140121 D "Affidavit for Financial Responsibility for Medical. Mental Health, Dental and/or Vision Care"
- DOC 140121 E "Record of Treatment by Community Health Care Provider"
- DOC 140121 F "After Clinic Hours-Transfer to Local/OUMC Hospital"
- DOC 140121 G "After Clinic Hours-Transfer to ER Note"
OP-140124
- DOC 140124 A "Initial Exam"
- DOC 140124 B "Dental Plaque Index"
- DOC 140124 C "Dental Treatment Plan"
- DOC 140124 D “Periodontal Charting”
- DOC 140124 E “Review for Partial Dentures”
- DOC 140124 F “Endodontic and Orthodontic Consent”
- DOC 140124 G “Request for Dental Exception”
OP-140125
- Attachment A "Decontamination Handbook for Bloodborne Pathogens"
- DOC 140125 A "Report of Injury or Unusual Occurrence/Encounter"
- DOC 140125 B "HIV Inmate Roster Review Log"
- DOC 140125 C "Hepatitis B Vaccine Declination Form"
OP-140127
- DOC 140127 A "Mental Health Unit, Intermediate Housing Care Unit or Habilitation Program Referral Form"
- DOC 140127 B "Evaluation Summary"
DOC 140127 C “Oklahoma Department of Corrections Mental Health Unit Intake”
OP-140129
- DOC 140129 A "Suicide Watch Log"
- DOC 140129 B "Risk Management Interview Worksheet"
- DOC 140129 C "Suicide Watch List"
- DOC 140129 D "Suicide Watch Conditions/Precautions"
- Attachment A "Psychological Autopsy"
OP-140130
- DOC 140130 A "Stock Order Form"
- DOC 140130 B "DOC Practitioner Cards Inventory and Reorder Form"
- DOC 140130 C "Monthly Stock Inventory Form"
- DOC 140130 D "Non-Formulary Medication Request Form"
- DOC 140130 E "Pharmaceutical Return Sheet"
- DOC 140130 G "Controlled Drug Stock Inventory Order Form Schedule III-V Only"
- DOC 140130 H "Medication Error Reporting Form"
- DOC 140130 J "Community Corrections Supervised Medication/Syringe Count Log or Supervised TDU Medication Log"
- DOC 140130 K "Suspected Adverse Drug Reaction (ADR) Reporting Form"
- DOC 140130 L "Barcode Medication Refill Form"
- DOC 140130 M "Medication Refill Slip (Split form)"
- DOC 140130 N "Medication Refill Slip (Single Form)"
- Attachment A "Approved Canteen OTC Medications"
- Attachment C "KOP vs. Pill Line by Security Level"
OP-140132
- DOC 140132 A "Refrigerator/Room Temperature Log"
- DOC 140132 B "Radiographic Report"
- DOC 140132 C "Optometric Service Record"
OP-140133
- DOC 140133A "ODOC Orthoses, Prostheses and Other Aids to Impairment Appliance Record"
OP-140137
- Attachment A "Severity Classification of Common Chronic Illness"
- Attachment B "Chronic Illness Management Guidelines-Routine and Annual Treatment Guidelines"
- DOC 140137 A " Chronic Clinic and/or Routine/Physical Examination"
- DOC 140137 B " RN/LPN Chronic Clinic Note"
OP-140138
- DOC 140138 A “ODOC Living Will/Advance Directive for Health Care”
- DOC 140138 B “ODOC Notification of Activation for a Living Will/Advance Directive and/or DNR”
- DOC 140138 C “ODOC Do Not Resuscitate (DNR) Consent Form”
OP-140140
- Attachment A "Mental Health Administration and Organization"
OP-140141
- Attachment A "Procedures for Four/Five Point Therapeutic Restraints"
- DOC 140141 A "Authorization for Application of Therapeutic Four/Five Point Restraints”
- DOC 140141 B "Restraint Medical Flow sheet”
- DOC 140141 C "Physical Restraint Log "
- DOC 140141 D “Certification Checklist for Safe/Therapeutic Seclusion/Restraint Cell”
- DOC 140141 E "Therapeutic Seclusion Watch Log"
- DOC 140141 F "Therapeutic Seclusion Conditions/Precautions"
OP-140142
- Attachment A "Provider Peer Review Criteria"
- Attachment B "Qualified Mental Health Professional Peer Review Criteria"
OP-140143
- DOC 140143 A "Notification of Medication Adherence"
OP-140146
- Attachment A "Edmonton Symptom Assessment Graph"
- Attachment B "Edmonton Symptom Assessment System Numerical Scale"
- Attachment C "Inmate Volunteer Agreement"
- Attachment D "Consent for Palliative Care"
OP-140147
- Attachment A "Male to Female (MtF) Hormonal Therapy Risk and Information Form"
- Attachment B "Female to Male (FtM) Hormonal Therapy Risk and Information Form"
- Attachment C "Request for Gender Dysphoria (GD) Evaluation/Treatment Algorithm"
- DOC 140147A “Referral for Gender Associated Requests”
OP-140201
- Attachment B "Mental Health Service Levels Classification System Criteria"
- DOC 140201A "Mental Health or Mental Status Review"
- DOC 140201 B “Mental Health Assessment for Restrictive Housing”
- DOC 140201 C "Abnormal Involuntary Movement Scale (AIMS)"
- DOC 140201 D "Facility Mental Health Needs Assessment and Strategic Plan Format"
OP-140301
- Attachment A "Sputum Collection"
- DOC 140301 A "Airborne Infection Isolation Room Checklist"
- DOC 140301 B "Tuberculosis and Immunization History Record"
- DOC 140301 C "Tuberculosis Summary Record"
- DOC 140301 D "Tuberculosis Questionnaire"
- DOC 140301 E "Preventative Therapy Waiver for Tuberculosis (TB) Infection"
- DOC 140301 F "Annual TB Summary Form"
- DOC 140301 G "RMP/EMB/PZA Tuberculosis Medication Regimen and Documentation"
- DOC 140301 H "INH/B6 Tuberculosis Medication Regimen and Documentation"
OP-140652
- DOC 140652A "Involuntary Medication Report"
- DOC 140652B "Notice of Hearing to Consider Recommendation of Involuntary Administration of Psychotropic Medication"
- DOC 140652C "Medication Review Committee Report"
- DOC 140652D "Involuntary Medication Hearing - Staff Representative Fact Sheet"
- DOC 140652E "Involuntary Medication Appeal Request"
- DOC 140652F "Involuntary Medication Appeal Decision"
OP-140701
- DOC 140701 A "Consent for Medical, Dental and Mental Health Treatment"
- DOC 140701 B "Vaccine Administration Consent/Refusal Form"
- DOC 140701 C "Informed Consent (Neuroleptics)"
- DOC 140701 D "Informed Consent for Telemedicine Services"
- DOC 140701E "Consent for Pain Treatment with Controlled Substances: Inmate Agreement"
- DOC 140701F "Consent for Dental Treatment"