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CLI.4510.FORM.005 Boundary Trails Health Centre Orthapedic Referral Form |
Trialing the Referral Form used at BTHC and made electronically fillable. |
For immediate use. All impacted departments are to remove any previous forms and replace. |
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CLI.4510.FORM.006 Ambulatory Care Clinic Referral Form |
Trialing the Referral Form used at BTHC and made electronically fillable. |
For immediate use. All impacted departments are to remove any previous forms and replace. |
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CLI.4510.FORM.007 Ambulatory Care Clinic Diabetic Foot Risk Assessment Referral |
Trialing the Referral Form used at BTHC and made electronically fillable. |
For immediate use. All impacted departments are to remove any previous forms and replace. |
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CLI.6611.PL.004 Surgical Count and Prevention of Retained Surgical Items |
Preventing patient from risks associated with Retained Surgical Items such as sponges, needles, miscellaneous items and instruments. Preventing harm to staff due to items lost in garbage and linen. Preventing items from being lost from inventory. |
Replace with existing forms. Site specific huddles to occur by CRN and team can implement once huddle has occurred. Complete Participation Record. |
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CLI.6611.PL.004.FORM.01 Operating Room Surgical |
Preventing patient from risks associated with Retained Surgical Items such as sponges, needles, miscellaneous items and instruments. Preventing harm to staff due to items lost in garbage and linen. Preventing items from being lost from inventory. |
Replace with existing forms. Site specific huddles to occur by CRN and team can implement once huddle has occurred. Complete Participation Record. |
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CLI.6611.PL.004.SD.01 Management of Throat Packs During Surgical Procedure Algorithm |
Preventing patient from risks associated with Retained Surgical Items such as sponges, needles, miscellaneous items and instruments. Preventing harm to staff due to items lost in garbage and linen. Preventing items from being lost from inventory. |
Replace with existing forms. Site specific huddles to occur by CRN and team can implement once huddle has occurred. Complete Participation Record. |
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CLI.6611.PL.004.SD.02 Periperative Count Reference |
Preventing patient from risks associated with Retained Surgical Items such as sponges, needles, miscellaneous items and instruments. Preventing harm to staff due to items lost in garbage and linen. Preventing items from being lost from inventory. |
Replace with existing forms. Site specific huddles to occur by CRN and team can implement once huddle has occurred. Complete Participation Record. |
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CLI.6611.PL.004.SD.03 Surgical Count Observational Audit Criteria |
Preventing patient from risks associated with Retained Surgical Items such as sponges, needles, miscellaneous items and instruments. Preventing harm to staff due to items lost in garbage and linen. Preventing items from being lost from inventory. |
Replace with existing forms. Site specific huddles to occur by CRN and team can implement once huddle has occurred. Complete Participation Record. |
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CLI.4110.FORM.005 Waiver of Responsibility and Liability |
Purpose of this Waiver of Responsibility and Liability is to provide a standardized Southern Health-Santé Sud form that combines all waivers of responsibility and liability relevant to inpatients. |
Form to be added to admission packages at all acute sites. Ensure to remove non-regional forms. |
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CLI.4110.PL.001 Consent for Procedures, Treatment and Investigations |
Updated name of Waiver of Responsibility form |
Read only |
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CLI.4110.PL.001.FORM.03 Waiver of Responsibility (Procedure, Treatment and Investigations) - Bilingual |
Updated name of Waiver of Responsibility form |
Program staff education as required |
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CLI.4110.PL.008 Interim Placement of Alternate Level of Care Patients |
Acute Care facilities in SH-SS will facilitate placement of ALC patients to optimize capacity. Facilitate the timely and most appropriate placement for person who no longer require Acute Care environments or who are paneled. |
Provide patients with letter when indicated, update Tracking Tool and complete ALC Patient Profile when required. |
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CLI.4110.PL.008.FORM.01 Information for Patients – Potential Transfer |
Acute Care facilities in SH-SS will facilitate placement of ALC patients to optimize capacity. Facilitate the timely and most appropriate placement for person who no longer require Acute Care environments or who are paneled. |
Provide patients with letter when indicated, update Tracking Tool and complete ALC Patient Profile when required. |
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CLI.4110.PL.008.FORM.01.F Information for Patients – Potential Transfer French |
Acute Care facilities in SH-SS will facilitate placement of ALC patients to optimize capacity. Facilitate the timely and most appropriate placement for person who no longer require Acute Care environments or who are paneled. |
Provide patients with letter when indicated, update Tracking Tool and complete ALC Patient Profile when required. |
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CLI.4110.PL.008.FORM.02 Patient Transfer Tracking Tool |
Acute Care facilities in SH-SS will facilitate placement of ALC patients to optimize capacity. Facilitate the timely and most appropriate placement for person who no longer require Acute Care environments or who are paneled. |
Provide patients with letter when indicated, update Tracking Tool and complete ALC Patient Profile when required. |
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CLI.4110.PL.008.FORM.03 Alternate Level of Care Patient Profile |
Acute Care facilities in SH-SS will facilitate placement of ALC patients to optimize capacity. Facilitate the timely and most appropriate placement for person who no longer require Acute Care environments or who are paneled. |
Provide patients with letter when indicated, update Tracking Tool and complete ALC Patient Profile when required. |
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CLI.4110.PL.013 Stroke Care |
Clinical Note circulated |
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CLI.4110.PL.013.FORM.01 Acute Stroke Care Map for Emergency Department in Non-Stroke Centres |
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CLI.4110.PL.013.FORM.02 Stroke Standard Orders – No TNK/24 Hours Post TNK |
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CLI.4110.PL.013.FORM.03 Minor Stroke Transient Ischemic Attack Risk Assessment and Standard Orders |
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CLI.4110.PL.013.FORM.04 Registration Clerk Notification – Bethesda Regional Heatlh Centre |
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CLI.4110.PL.013.FORM.05 Registration Clerk Notification – Boundary Trails Health Centre |
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CLI.4110.PL.013.FORM.06 Registration Clerk Notification – Portage Regional Health Centre |
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CLI.4110.PL.013.FORM.07 Stroke Centres Emergency Standard Orders |
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CLI.4110.PL.013.FORM.08 Stroke Centres Emergency Standard Orders Transcribed |
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CLI.4110.PL.013.FORM.11 New Onset of Suspected Stroke Symptoms on Inpatients Units within a Stroke Centre |
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CLI.4110.PL.013.SD.01 STROKE Transient Ischemic Attach Algorithm for Responses in Community |
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CLI.4110.PL.013.SD.02 Hyperacute Stroke Algorithm for Stroke Centres |
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CLI.4110.PL.013.SD.03 Stroke Algorithm for Suspected Intracerebral Hemorrhage Post INK |
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CLI.4110.PL.013.SD.04 Management of Angioedema Caused by TNK use in Acute Ischemic Stroke |
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CLI.4110.PL.013.SD.05 Stroke Care Audit Criteria – Stroke Centres Emergency Departments |
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CLI.4110.PL.013.SD.06 Stroke Care Audit Criteria – Non-Stroke Centres Emergency Departments |
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CLI.6410.PL.037 Medical Services in Personal Care Homes and Transitional Care |
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CLI.6410.PL.037.FORM.01 Medical History and Physical Exam Form – Personal Care Home/Transitional Care |
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CLI.6410.PL.037.SD.01 Lab Investigations in Personal Care Home/Transitional Care |
Standard Guideline CLI.6410.SG.002 has been archived and changed to a policy, revised to include Transitional Care and updated to current practices |
Read only |
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CLI.5410.PL.007 Working Alone Safety Assessment |
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CLI.5410.PL.007.FORM.01 Working Alone Safety Assessment Safe Visit Plan |
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CLI.5410.PL.007.FORM.02 Safe Visit Plan |
To identify risk factors in the client’s home environment that may affect safety of clients & staff. To assist in the development of safe visit plans. Updated to reflect changes. |
Read only |
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CLI.5410.PL.007.SD.01 Client Guidelines for Workplace Safety and Health |
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CLI.5410.PL.007.SD.01.F Client Guidelines for Workplace Safety and Health - French |
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CLI.5410.PL.007.SD.02 Working Alone Safety Assessment and Safe Visit Plan Resource Coordinator and Scheduling Clerk |
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CLI.5410.PL.007.SD.03 Working Alone Safety Assessment and Safe Visit Plan Nurse Scheduler |
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