Forms

Contact List - A helpful list of numbers for our clinicians.

Anti-Coagulation Flow Sheet - A two sided worksheet designed to support ECP, PA's recommended Anticoagulation Policy.

Medical Director's Meeting Log - A form designed to help practicing Nursing Facility Medical Directors document their activities. The listed activities are stated in language that corresponds to the job duties outlined by AMDA and CMS.

Dictation Guide for Nursing - A collaborative form for use by a Facility's nursing staff and the rounding physician. It is designed to communicate pertinent patient information, and nursing observations to the Physician. The Physician uses the form to note his/her observations, findings, and plans, so they are in order for subsequent dictation/transcription.

Physical Exam Form - A template and worksheet for use with comprehensive patient assessments which follows the sequence of ECP's electronic medical record (EMR).

MOST - is an acronym for 'Medical Orders for Scope of Treatment'. This form can replace our less comprehensive DNR form as the primary document to guide clinicians when treating seriously ill patients. ECP encourages facilities to learn how to use this form and adopt it in their procedures for documenting End of Life choices for patients. This form increses the likelihood that an On-Call Physician will render treatment consistent with patient/family desires. To order the forms, follow this link: http://www.ncdhhs.gov/dhsr/EMS/pdf/mostorderform2.pdf

• Additional MOST Documents:
  • Guide for Public Education JAN2009
  • MOST Procedures
  • MOSTGuide B - Guide for Patients DEC2008
  • MOST FAQ