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To view, download or print any of the forms Outpatient Surgery Magazine offers online, please select it from the choices below. Note: Documents marked with "PDF" (portable document format) are readable with Acrobat Reader, available here for free. Documents marked with "XLS" (Excel spreadsheet) are readable with Microsoft Excel or any spreadsheet software. 
Perioperative Block Record
Courtesy of Cathy Rice, MD Making Time for Blocks References
Courtesy of Michael F. Mulroy, MD Financial Management of the Center
Courtesy of Outpatient Surgery Magazine Editors Pre-op Form 1: Patient Questionnaire
Courtesy of Truvista Surgery Center Pre-op Form 2: Medication Form
Courtesy of Truvista Surgery Center 
3 Steps to Right-sizing Your Suture Stock
Courtesy of Robert Schaff Why Scrub When You Can Rub? References
Courtesy of Janet P. Haas, RN, DNSc, CIC What's Your Consciousness Telling You? References
Courtesy of Colletta A. Richards, MD Diet Sheet
Courtesy of Denise Kohler, RN, BSN, MSN Prep Instructions
Courtesy of Denise Kohler, RN, BSN, MSN Contract Checklist
Courtesy of Alicia R. Cooper, Little Rock, Arkansas Eye Preps: When You Can't Use Povidone Iodine
Courtesy of Jean Hill, RN, MSN, CRNO and Lisa (Mary) Hill, RN, BSN The Essentials of Competency Programs for Ambulatory Surgery and Hospital Outpatient Settings
Courtesy of Dawn Q. McLane, RN, MSA, CASC, CNOR 
Surgical Pricing Schedule
Courtesy of Jay Schorr of Advanced Cosmetic Laser Center "How to Head off Deep Vein Thrombosis" References, June 2006
Courtesy of Anita Johnston, RN, BSN, CNOR 2006 Medicare Injection and Infusion Flowchart
Courtesy of Lolita M. Jones, RHIA Orthopaedic Discharge Form
Courtesy of Lacey Dyer, RN Sample Assignment of Benefits Form
Courtesy of MedBridge Development, LLC Safety References, May 2006
Courtesy of Scott DeBoer, RN, MSN, CEN, CCRN, CFRN Sample Provisions for Partnership Agreements
Courtesy of Scott Becker, JD, CPA and Alison Vratil Mikula, JD of McGuire Woods in Chicaco, Ill. "Busting 7 Back Injury Myths" and "Inside the Numbers" References, March 2006
Courtesy of Jamie Tessler, MPH Sample Surgeon Survey
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI Ambulatory Surgery: Surgical Site Infection Surveillance (part 1)
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI Ambulatory Surgery: Surgical Site Infection Surveillance (part 2)
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI Infection Control Construction/Renovation Monitoring Checklist
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI Infection Control Construction Permit
Courtesy of Janice E. Rey, MP (ASCP), CIC, St. John Hospital and Medical Center, Detroit, MI Unanticipated Care After Discharge From Ambulatory Surgical Facilities
Courtesy of The Patient Safety Authority January, 2006 Safety Column References
Courtesy of Joy L. Hawkins, MD 
Patient Surgery Cost Sheet
Courtesy of Betsy Sharp, Administrator, Orthopaedic Associates Surgery Center LLC in Augusta, Georgia Precertification for Surgery Form
Courtesy of Betsy Sharp, Administrator, Orthopaedic Associates Surgery Center LLC in Augusta, Georgia General Post-operative Guidelines for Patients with Known History of Obstructive Sleep Apnea Requiring Use of CPAP
Courtesy of Marjorie N. Blouin, RN and Shannon Magro, RN, Frederick Surgical Center, Frederick, Maryland PCC BMI/CPAP Protocol
Courtesy of Marjorie N. Blouin, RN and Shannon Magro, RN, Frederick Surgical Center, Frederick, Maryland Myths of Pediatric Anesthesia References
Courtesy of Zeev Kain, MD, MBA, Professor and Chief of Pediatric Anesthesiology, Yale University School of Medicine Vacation & Sick Leave Accrual and Utilitization
Courtesy of Kristine Bedford, RN, Clinical Director, Endoscopy Center of Marin, Greenbrae, California Adverse Incident Report
Courtesy of The American Society of Plastic Surgeons Penicillin Allergy Algorithm
Courtesy of Outpatient Surgery Magazine Adult Pre-Operative Antibiotic Physicians Order Form
Courtesy of Southwest Generat Hospital Center, Middleburg, Ohio Operating Room Par Levels
Courtesy of Beverly Kirchner, RN, BSN, CNOR, CASC Sample Narcotics Form
Courtesy of Kris Fisher, RN, CNOR, BSN, Turtle Creek Surgery Center Checklist for Adding a Service Line
Courtesy of Sharon Davis, RN, RVT July "Legal Update" References
Courtesy of Outpatient Surgery Editors Plastic Surgery Safety Checklist
Compiled by Contributing Editor Dianne Taylor NCMC/SPC Case Cart Quality Inspection Sheet
Courtesy of Jennifer L. Misajet, RN, BBA, CNOR: Director of Surgical Services, Western States Burn Center Initial Appeal Documentation
Courtesy of Deborah L. Mack, MSN, CASC, CNOR Sample EOC Plan
Courtesy of Nancy Burden, RN, MS, CPAN, CAPA Example Table of Contents for Administration Manuals
Courtesy of Nancy Burden, RN, MS, CPAN, CAPA Coding the Most Common Colonoscopies
Courtesy of Stephanie Ellies, RN, CPC Sample Side-by-Side Surgical Lighting Trial Evaluation Form
Courtesy of Phyllis Rozema, BS, Borgess Hospital, Kalamazoo, Michigan March "Overcoming the Roadblocks to Regional Anesthesia" References
Courtesy of Outpatient Surgery Magazine Evaluating Skin Preps Pullout Full Version
Download by page: Courtesy of Outpatient Surgery Magazine February "Fast Facts About Fast Track Anesthesia" References
Courtesy of Outpatient Surgery Magazine NCMC/SPC Case Cart Quality Inspection Sheet
Courtesy of Jennifer L. Misajet, RN, BBA, CNOR: Director of Surgical Services, Western States Burn Center Medicare Survey Checklist
Courtesy of Genesee Associates, Inc. Employee Human Resource File: Chart Order
Courtesy of Genesee Associates, Inc. Initial Medical Executive Committee/Board Meeting Surgery Center
Courtesy of Genesee Associates, Inc. Surgery Center Organizational Chart
Courtesy of Genesee Associates, Inc. Development Team Assignments / Time Line: Surgery Center
Courtesy of Genesee Associates, Inc. 
Medicare Program; Update of Ambulatory Surgical Center List of Covered Procedures
Courtesy of Department of Health and Human Services "If You're Thinking of Buying..." References
Courtesy of Outpatient Surgery Magazine Crash Cart Inventory Checklist
Courtesy of Progressive Surgical Solutions, LLC. Pain Management Fee Schedule
Courtesy of Mowles Medical Practice Management, LLC. Surgical Glove Evaluation
July, 2004 - 107kb - PDF Sample Man Hours/Case Worksheet
Courtesy of Caryl A. Serbin, RN, BSN, LHRN Sample Surgical Site Infection Tracking Form
Adapted from St. John’s Mercy Medical Center Infection Control Department Professional Associations and Nursing Organizations
Courtesy of Ann Geier, RN, MS, CNOR Patient-Controlled Analgesia (PCA) Pump Safety Protocol
Courtesy of Institute for Safe Medication Practices (ISMP), Huntingdon Valley, Pa. Nurse Endoscopy Training Protocol
Courtesy of Alaska Native Medical Center, Anchorage, Alaska. Flexible Sigmoidoscopy Screening Protocol
Courtesy of National Naval Medical Center Division of Gastroenterology, Bethesda, Md. Index of Corporate Partners, Managers and Consultants A Sample Policy on Supply Pilfering
Courtesy of Jerrie Smith Provider-Specific Trends: Rennaissance and Baroque Artists Hospital
Courtesy of Siegel and Krohn, PC 2004 Patient Safety Principles for Office-Based Surgery Utilizing Moderate Sedation/Analgesia, Deep Sedation/Analgesia, or General Anesthesia
Courtesy of American College of Surgeons The Fraud and Abuse Statute and Investor-Owned Ambulatory Surgery Centers
Courtesy of Scott Becker and Nicholas Harned 4 Tips for Assessing Post-op Pain in Elderly Patients
Courtesy of M. McCaffrey and C. Pasero A Latex Allergy Patient Screening Questionnaire
Courtesy of Lauren Charous, MD Size: 78kb
Type: PDF |
