Sync template from atomicqms-style deployment

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2025-12-27 11:24:08 -05:00
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# Nursing Admission Assessment
| Form ID | FRM-INP-001 | Revision | 1.0 |
|---------|-------------|----------|-----|
---
## Patient Information
| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Admission Date | |
| Admission Time | |
| Admitting Physician | |
| Unit/Room | |
| Admitting Diagnosis | |
| Source of Admission | ☐ Home ☐ ED ☐ Transfer ☐ Other: _______ |
| Mode of Arrival | ☐ Ambulatory ☐ Wheelchair ☐ Stretcher |
---
## Vital Signs
| Parameter | Value | Time |
|-----------|-------|------|
| Temperature | °F / °C | |
| Heart Rate | bpm | |
| Respiratory Rate | breaths/min | |
| Blood Pressure | / mmHg | |
| SpO2 | % on ☐ RA ☐ O2 ___L/min | |
| Pain Level | /10 | |
| Height | | |
| Weight | | |
---
## Allergies
☐ No Known Allergies (NKA)
☐ No Known Drug Allergies (NKDA)
| Allergen | Type | Reaction |
|----------|------|----------|
| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
| | ☐ Drug ☐ Food ☐ Environmental ☐ Other | |
**Allergy band applied?** ☐ Yes ☐ N/A
---
## Current Medications
| Medication | Dose | Frequency | Last Taken | Continue? |
|------------|------|-----------|------------|-----------|
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
| | | | | ☐ Yes ☐ No |
**Medication source:** ☐ Patient/Family ☐ Pharmacy Records ☐ PCP Records ☐ Other: _______
**Medications brought to hospital?** ☐ Yes (inventory attached) ☐ No
---
## Medical History
### Past Medical History
☐ None significant
| Condition | Notes |
|-----------|-------|
| ☐ Hypertension | |
| ☐ Diabetes | Type: ☐ 1 ☐ 2 |
| ☐ Heart Disease | |
| ☐ COPD/Asthma | |
| ☐ Stroke/TIA | |
| ☐ Cancer | Type: |
| ☐ Kidney Disease | |
| ☐ Liver Disease | |
| ☐ Seizures | |
| ☐ Psychiatric | |
| ☐ Other: | |
### Past Surgical History
☐ None
| Surgery/Procedure | Year |
|-------------------|------|
| | |
| | |
| | |
---
## Review of Systems
### General
- ☐ Fatigue/Weakness
- ☐ Fever/Chills
- ☐ Weight Change
- ☐ Night Sweats
### Cardiovascular
- ☐ Chest Pain
- ☐ Palpitations
- ☐ Edema
- ☐ Shortness of Breath with Activity
### Respiratory
- ☐ Cough
- ☐ Shortness of Breath at Rest
- ☐ Oxygen Use at Home
- ☐ CPAP/BiPAP Use
### Gastrointestinal
- ☐ Nausea/Vomiting
- ☐ Abdominal Pain
- ☐ Diarrhea
- ☐ Constipation
- ☐ Blood in Stool
### Genitourinary
- ☐ Incontinence
- ☐ Dysuria
- ☐ Urgency/Frequency
- ☐ Foley Catheter
### Neurological
- ☐ Numbness/Tingling
- ☐ Weakness
- ☐ Confusion
- ☐ Dizziness/Vertigo
### Skin
- ☐ Rash
- ☐ Open Wounds
- ☐ Bruising
---
## Pain Assessment
| Field | Entry |
|-------|-------|
| Pain Present? | ☐ Yes ☐ No |
| Location | |
| Character | ☐ Sharp ☐ Dull ☐ Aching ☐ Burning ☐ Stabbing |
| Intensity (0-10) | |
| Duration | ☐ Constant ☐ Intermittent |
| Aggravating Factors | |
| Relieving Factors | |
| Current Pain Management | |
---
## Fall Risk Assessment
**Morse Fall Scale** (or institutional tool)
| Risk Factor | Score |
|-------------|-------|
| History of falling | ☐ No (0) ☐ Yes (25) |
| Secondary diagnosis | ☐ No (0) ☐ Yes (15) |
| Ambulatory aid | ☐ None/Bed rest/Nurse assist (0) ☐ Crutches/Cane/Walker (15) ☐ Furniture (30) |
| IV/Heparin Lock | ☐ No (0) ☐ Yes (20) |
| Gait | ☐ Normal/Bed rest/Immobile (0) ☐ Weak (10) ☐ Impaired (20) |
| Mental Status | ☐ Oriented to own ability (0) ☐ Overestimates/forgets limitations (15) |
| **Total Score** | |
**Risk Level:**
- ☐ Low Risk (0-24)
- ☐ Moderate Risk (25-44)
- ☐ High Risk (≥45)
**Fall precautions initiated?** ☐ Yes ☐ N/A
---
## Pressure Ulcer Risk Assessment
**Braden Scale**
| Category | Score (1-4) |
|----------|-------------|
| Sensory Perception | |
| Moisture | |
| Activity | |
| Mobility | |
| Nutrition | |
| Friction/Shear | |
| **Total Score** | |
**Risk Level:**
- ☐ Mild Risk (15-18)
- ☐ Moderate Risk (13-14)
- ☐ High Risk (10-12)
- ☐ Very High Risk (≤9)
**Skin interventions initiated?** ☐ Yes ☐ N/A
---
## Skin Assessment
☐ Skin intact, no abnormalities noted
**Abnormalities (document location and description):**
| Location | Description | Size | Stage/Type |
|----------|-------------|------|------------|
| | | | |
| | | | |
---
## Nutritional Screen
| Field | Entry |
|-------|-------|
| Diet at Home | |
| Recent Weight Loss? | ☐ Yes (____lbs in ____weeks) ☐ No |
| Difficulty Swallowing? | ☐ Yes ☐ No |
| Dentures? | ☐ Yes ☐ No |
| Food Allergies/Intolerances | |
| Special Diet Needs | |
**Dietitian Referral Needed?** ☐ Yes ☐ No
---
## Functional Assessment
### Mobility
- ☐ Independent
- ☐ Assistive Device: _______
- ☐ Requires Assistance
- ☐ Bed Bound
### Activities of Daily Living
| Activity | Independent | Needs Assistance | Dependent |
|----------|-------------|------------------|-----------|
| Bathing | ☐ | ☐ | ☐ |
| Dressing | ☐ | ☐ | ☐ |
| Toileting | ☐ | ☐ | ☐ |
| Feeding | ☐ | ☐ | ☐ |
| Transfers | ☐ | ☐ | ☐ |
---
## Psychosocial Assessment
| Field | Entry |
|-------|-------|
| Living Situation | ☐ Alone ☐ With Family/Spouse ☐ Assisted Living ☐ SNF ☐ Other: _______ |
| Primary Caregiver | |
| Emergency Contact | |
| Contact Phone | |
| Relationship | |
| Barriers to Care | ☐ None ☐ Language ☐ Transportation ☐ Financial ☐ Other: _______ |
| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
---
## Advance Directives
| Field | Entry |
|-------|-------|
| Advance Directive on File? | ☐ Yes ☐ No ☐ Unknown |
| Healthcare Proxy/POA? | ☐ Yes (Name: _______) ☐ No |
| Copy Obtained? | ☐ Yes ☐ No ☐ N/A |
| Code Status | ☐ Full Code ☐ DNR ☐ DNR/DNI ☐ Comfort Care Only |
| Physician Order for Code Status? | ☐ Yes ☐ Pending |
---
## Discharge Planning Screen
| Field | Entry |
|-------|-------|
| Anticipated Discharge Disposition | ☐ Home ☐ Home with Services ☐ Rehab ☐ SNF ☐ Unknown |
| DME Needs Anticipated? | ☐ Yes ☐ No ☐ Unknown |
| Home Health Needs? | ☐ Yes ☐ No ☐ Unknown |
| Case Management Referral? | ☐ Yes ☐ No |
| Social Work Referral? | ☐ Yes ☐ No |
---
## Safety Measures Initiated
- [ ] Fall precautions per risk level
- [ ] Skin precautions per risk level
- [ ] Call light within reach
- [ ] Bed in low position
- [ ] Side rails per policy
- [ ] Patient education on safety
---
## Orientation Provided
- [ ] Room orientation (call light, bathroom, bed controls)
- [ ] Visiting hours
- [ ] Unit phone number
- [ ] Patient rights information
- [ ] Advance directive information
- [ ] Valuables policy
---
## Assessment Completion
| Field | Entry |
|-------|-------|
| Assessment Completed By | |
| Credentials | |
| Date | |
| Time | |
| Signature | |
---
*Form FRM-INP-001 Rev 1.0 - Nursing Admission Assessment*

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# Document Change Request Form
| Form ID | FRM-001 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: Request Information
| Field | Entry |
|-------|-------|
| Request Date | |
| Requested By | |
| Department | |
## Section 2: Document Information
| Field | Entry |
|-------|-------|
| Document Number | |
| Document Title | |
| Current Revision | |
## Section 3: Change Description
### Type of Change
- [ ] New Document
- [ ] Revision to Existing Document
- [ ] Document Obsolescence
### Description of Change
*(Describe the proposed change in detail)*
### Reason for Change
*(Explain why this change is needed)*
## Section 4: Impact Assessment
### Affected Areas
- [ ] Training Required
- [ ] Other Documents Affected
- [ ] Process Changes Required
- [ ] Validation Impact
### List Affected Documents
## Section 5: Approvals
| Role | Name | Signature | Date |
|------|------|-----------|------|
| Requester | | | |
| Document Owner | | | |
| Quality Assurance | | | |
---
*Form FRM-001 Rev 1.0*

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# Corrective and Preventive Action (CAPA) Form
| Form ID | FRM-003 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: CAPA Identification
| Field | Entry |
|-------|-------|
| CAPA Number | |
| Date Initiated | |
| Initiated By | |
| CAPA Owner | |
| Target Closure Date | |
## Section 2: Classification
### Type
- [ ] Corrective Action
- [ ] Preventive Action
### Source
- [ ] Customer Complaint
- [ ] Internal Audit
- [ ] External Audit
- [ ] Process Deviation
- [ ] Nonconforming Product
- [ ] Management Review
- [ ] Other: ____________
### Priority
- [ ] Critical (5 business days)
- [ ] Major (15 business days)
- [ ] Minor (30 business days)
## Section 3: Problem Description
*(Describe the nonconformity or potential nonconformity)*
## Section 4: Immediate Containment
*(Actions taken to contain the immediate impact)*
## Section 5: Root Cause Investigation
### Investigation Method Used
- [ ] 5 Whys
- [ ] Fishbone Diagram
- [ ] Fault Tree Analysis
- [ ] Other: ____________
### Root Cause Determination
## Section 6: Corrective/Preventive Actions
| Action | Responsible | Due Date | Status |
|--------|-------------|----------|--------|
| | | | |
| | | | |
| | | | |
## Section 7: Effectiveness Verification
| Criteria | Method | Result |
|----------|--------|--------|
| | | |
Verification Date: ____________
Verified By: ____________
## Section 8: Closure
| Role | Name | Signature | Date |
|------|------|-----------|------|
| CAPA Owner | | | |
| Quality Approval | | | |
---
*Form FRM-003 Rev 1.0*

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# Internal Audit Checklist
| Form ID | FRM-006 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Audit Information
| Field | Entry |
|-------|-------|
| Audit Number | |
| Audit Date | |
| Area/Process Audited | |
| Lead Auditor | |
| Auditee(s) | |
---
## Checklist Items
| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes |
|---|---------------------|-----------|---------|----------------|
| 1 | Are current versions of applicable procedures available? | SOP-001 | | |
| 2 | Are personnel trained on applicable procedures? | SOP-003 | | |
| 3 | Are training records current and complete? | SOP-003 | | |
| 4 | Are records properly maintained and retrievable? | SOP-001 | | |
| 5 | Are nonconformities being documented and addressed? | SOP-002 | | |
| 6 | Are CAPAs being completed on time? | SOP-002 | | |
| 7 | Is equipment calibrated and maintained? | | | |
| 8 | Are process controls being followed? | | | |
| 9 | Are quality objectives being monitored? | | | |
| 10 | | | | |
**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable
---
## Findings Summary
| Finding # | Type | Description | Clause Reference |
|-----------|------|-------------|------------------|
| | | | |
| | | | |
---
## Auditor Signature
| Auditor | Signature | Date |
|---------|-----------|------|
| | | |
---
*Form FRM-006 Rev 1.0*

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# Training Record Form
| Form ID | FRM-004 | Revision | 1.0 |
|---------|---------|----------|-----|
---
## Section 1: Employee Information
| Field | Entry |
|-------|-------|
| Employee Name | |
| Employee ID | |
| Department | |
| Job Title | |
## Section 2: Training Information
| Field | Entry |
|-------|-------|
| Training Title | |
| Training Date | |
| Training Duration | |
| Trainer Name | |
| Trainer Qualification | |
### Training Type
- [ ] Initial Training
- [ ] Retraining
- [ ] Refresher
- [ ] Procedure Update
### Delivery Method
- [ ] Classroom
- [ ] On-the-Job
- [ ] Self-Study
- [ ] Computer-Based
- [ ] Other: ____________
## Section 3: Training Content
*(List topics covered or attach training materials)*
## Section 4: Assessment
### Assessment Method
- [ ] Written Test
- [ ] Practical Demonstration
- [ ] Verbal Assessment
- [ ] Observation
### Assessment Results
| Metric | Result |
|--------|--------|
| Score (if applicable) | |
| Pass/Fail | |
## Section 5: Signatures
| Role | Name | Signature | Date |
|------|------|-----------|------|
| Trainee | | | |
| Trainer | | | |
| Supervisor | | | |
---
*Form FRM-004 Rev 1.0*