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Standard Assessment Tool
Mark Wound Location
Wound Assessment +
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Form NameStandard Assessment Tool
URLforms.aidbox.io/questionnaire/…
Version0.1.0
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QuestionnaireResponsePopulationData ExtractionNamed Expressions
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draft—27 May—
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16 forms50 / pageVersioned — every save is a new version
Forms Demo / Library
Wound Any
MDS v3.0 - RAI v1.18.11 - Nursing home comprehensive (NC) item set
loinc.org/q/101105-5
MDS v3.0 - RAI v1.18.11 - Nursing home quarterly (NQ) item set
loinc.org/q/101106-3
MDS v3.0 - RAI v1.18.11 - Nursing home discharge (ND) item set
loinc.org/q/101107-1
MDS v3.0 - RAI v1.18.11 - Interim Payment Assessment (IPA)
loinc.org/q/101111-3
MDS v3.0 - RAI v1.18.11 - Swing bed PPS (SP) item set
loinc.org/q/101112-1
Wound Assessment Pnl
loinc.org/q/39135-9
Outcome and assessment information set (OASIS) — version B1
loinc.org/q/46462-8
MDS full assessment form — version 2.0
loinc.org/q/45981-8
Continuity assessment record — Acute care
loinc.org/q/52743-2
80 forms · Regenstrief Institute, Inc.
Wound Assessment ×
Body site
Body site front and back diagram
Wound bed and edge panel
Wound bed panel
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Consent for
Medical/Surgical Care/Emergency Treatment
and Child's Medical Information
In presenting my son/daughter for diagnosis and treatment
Name:for
Mother Father Legal Guardian Son Daughter
of years of age, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, surgical and medical treatment and blood transfusions, by authorized members of the hospital staff or their designees, as may in their professional judgment be necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child's condition.
I have read this form and certify that I understand its contents.
We/I hereby give our (my) consent to
(Name of Person/Agency)
who will be caring for our (my) child
(Name of Child)
for the period to to arrange for routine or emergency medical/dental care and treatment necessary to preserve the health of our (my) child.
We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.
Name:
Family physician:
Address:
Pediatrician:
Telephone no.:
Surgeon:
Name of health insurance carrier:
Orthopedist:
Child's allergies, if any:
Group no.:
Date of last tetanus booster:
Agreement no.:
Medicines child is taking:
Signature:
Date:
Witness:
Date:
In case of emergency I can be reached at:
Import Questionnaire×
consent.pdf×
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{ "resourceType": "Questionnaire", "id": "consent-medical-surgical-emergency-child-medical-info", "status": "draft", "title": "Consent for Medical/Surgical Care/Emergency Treatment...", "language": "en", "item": [ { "linkId": "sec-1", "type": "group", "text": "Consent for Medical/Surgical Care...", "item": [ { "linkId": "sec-1-intro", "type": "display", "text": "In presenting my son/daughter..." }, { "linkId": "sec-1-presenting-name", "type": "text", "text": "Name" }, { "linkId": "sec-1-presenting-for", "type": "text", "text": "for"
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Extracted in 3.2sQuestionnaire/consent-medical-surgical-emergency-child-medical-info