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This document is a blood transfusion consent form for Miss. Ayesha Ajhar Shaikh, a 15-year-old female patient admitted to Sanjeevani Multispeciality Hospital on September 19, 2023. The form details the potential risks of blood transfusion that were explained to the patient, including transmission of infectious diseases. It also states that the hospital tests all blood for several diseases and infections. While no tests can guarantee that infections will not be transmitted, the patient understands the risks and provides consent for a blood transfusion if needed for her care. The form requires signatures from the patient, doctor, and witnesses.
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![Sanjeevani Multispeciality Hospital
Plot No. 17, Rishi Park, Ambad Chowfully, JALNA 431203
Blood Transfusion Consent
UHID : SHJ-124903 IPD Sr No : 17284
Patient Name : Miss. Ayesha Ajhar Shaikh DOA : 19-Sep-2023
Age /Sex : 15 / Female Time : 10:30:00 AM
Address : Partur Jalna Relative : .
Mobile : 9834274459 Relation : ..
Under Care of : Dr. Shivdas Mirkad, Contact No. : 9834274459
Room : 306 - Semi Special Company : Self
Dr.__________________________________________ has explained to me the Potential complications of transfusion of blood/
blood products which include the risk of transmission of infectious diseases such as Hepatitis ,HIV-AIDS and other bacterial and
parasitic diseases, allergic and febrile reactions etc.
I understand that all units of blood collected in the blood bank of Hospital are tested for antibodies to HIV1/ HIV2, Hepatitis C,
Hepatitis B, Surface Antigen, Syphilis(Rapid Plasma Regain Test) and screened for Malarial Parasite; and that only units that are
negative for these infectious diseases are released for transfusion; and that sterility checks and quality control procedures are
regularly performed on samples of blood components.
I also realize that no known test method can offer complete assurance that products derived from human sources will not transmit
infection.
I have read and understood this document and had a chance to clarify my doubts.
If need arises for the transfusion of blood /products as part of my care ,I here by give consent to such transfusion.
If patient is Unable to give consent the entire content may be explained to a relative, who signs mentioning the
relationship to the patient.
Patient Name:________________________________Signature:_________________Date:_____________Time:_____________
If patient is unable to sign, the name and relation of the person signing on his/her behalf
Name:______________________________________Signature:__________________Date:_____________Time:_____________
Doctor's
Name:_______________________________Signature:__________________Date:_____________Time:_____________
Witness on behalf at the Patient:
Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________
Witness on behalf of the Hospital:
Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________
Interpreter's Statement:
Specific language requirements (if any)
Interpreter services required: [ ] Yes [ ] No
I confirm that I have accurately interpreted the contents of this form, and the related conversation/s between the patient / person
giving consent and the doctor.
Interpreter's
Name:_______________________________Signature:__________________Date:_____________Time:_____________](https://image.slidesharecdn.com/printipdpaper-230920093618-6bf8e07d/85/Print-IPD-Paper-pdf-1-320.jpg)
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Dr. Archibald M. Graham
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CONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSIONCONDITIONS OF ADMISSION
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____2. What you have heard from other professionals in informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on data you have gathered systematically and regularly
____5. What fits your personal style
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____1. The physician’s intuition (gut feeling) that a method will work
____2. What he or she has heard from other physicians in informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success based on data he or she has gathered systematically and regularly
____5. What fits his or her personal style
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This permission slip collects information from a student such as their name, date of birth, address, contact details, allergies, and any medications they need to manage. It asks if they can manage their own medications or need an adult present. Any other concerns are requested. The student must agree that they understand any injuries are not the fault of those involved in the activity and a parent/guardian signature is also required.
Elevate sign up-2013
This document is a registration and participation agreement form for the Elev8 event being held from May 24-27, 2013 at Point Loma Nazarene University in San Diego, California. It collects information on the participant and emergency contacts, includes medical and insurance information, and has the participant and guardian agree to the rules, accept liability, and consent to medical treatment if needed.
Consent form centralvenouscatheter
This document is an informed consent form for a central venous catheter procedure. It details that the patient permits their attending physician and assistants to perform the central venous catheter procedure. It explains that the risks, benefits, and alternatives have been discussed with the patient. The patient acknowledges they understand there are risks to any medical procedure and have been provided enough information to give informed consent. The patient agrees to blood transfusions if needed and allows any removed tissue to be used or disposed of by the facility.
Youth activities consent
all christian church must know everything by laws for church own thing,
many thanks
GOD BLESS YOU All
Medical release form
This document is a sample consent form for releasing medical information. It authorizes a specific health care provider to disclose a patient's health information to identified recipients for a stated purpose. The patient can specify what information is released, such as all records, specific types of information, or limiting the term of release. The patient acknowledges the information may be redisclosed without restrictions after release. The consent can be refused or revoked by the patient at any time.
Situations 1 and 2 Making Decisions About InterventionsSitua.docx
Situations 1 and 2: Making Decisions About Interventions*
Situation 1
Think back to a client (individual, family, group, agency, or community) with whom you have worked. Place a check mark next to each criterion you used to make your practice decision. If you have not yet worked with a client, think of the criteria on which you would probably rely.
____1. Your intuition (gut feeling) about what will be effective
____2. What you have heard from other professionals in informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on data you have gathered systematically and regularly
____5. What fits your personal style
____6. What was usually offered at your agency
____7. Self-reports of other clients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What you are most familiar with
____10. What you know by critically reading professional literature
Situation 2
Imagine you have a potentially serious medical problem and you seek help from a physician to examine treatment options. Place a check mark next to each criterion you would like your physician to rely on when he or she makes recommendations about your treatment.
____1. The physician’s intuition (gut feeling) that a method will work
____2. What he or she has heard from other physicians in informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success based on data he or she has gathered systematically and regularly
____5. What fits his or her personal style
____6. What is usually offered at the clinic
____7. Self-reports of patients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What the physician is most familiar with
____10. What the physician has learned by critically reading professional literature
*From Gambrill, E., & Gibbs, L. (2017). Making decisions about intervention. In Criticalthinking for helping professionals: A skills-based workbook (4th ed., pp. 69–70). New York, NY: Oxford University Press.
Module 03
Course Project - Part 1
PATIENT REGISTRATION FORM
Practice – The People’s Clinic
Address – 1000 Town Square, Anytown Pennsylvania 54321
Phone – 555-741-8529
PATIENT INFORMATION
Patient – Mrs. Jane Doe
Married
Former name – Jane Smith
DOB – 01/01/1960
SSN - 123-45-6789
Address – 123 Main Street, Anytown Pennsylvania 54321
Phone – 555-987-6543
Occupation – Nurse
Employer – The People’s Hospital
Employer Phone – 555-456-7890
Doctor referral to clinic
INSURANCE INFORMATION
Jane Doe is responsible for payment
Primary insurance is Blue Cross Blue Shield
Subscriber – Jane Doe
ID – 123123123
Grp – 00550055
No secondary insurance
IN CASE OF EMERGENCY
Suzie Smith (sister)
Home – 555-567-8910
Work – 555-678-9012
.
Situations 1 and 2 Making Decisions About InterventionsSitua.docx
Situations 1 and 2: Making Decisions About Interventions*
Situation 1
Think back to a client (individual, family, group, agency, or community) with whom you have worked. Place a check mark next to each criterion you used to make your practice decision. If you have not yet worked with a client, think of the criteria on which you would probably rely.
____1. Your intuition (gut feeling) about what will be effective
____2. What you have heard from other professionals in informal exchanges
____3. Your experience with a few cases
____4. Your demonstrated track record of success based on data you have gathered systematically and regularly
____5. What fits your personal style
____6. What was usually offered at your agency
____7. Self-reports of other clients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What you are most familiar with
____10. What you know by critically reading professional literature
Situation 2
Imagine you have a potentially serious medical problem and you seek help from a physician to examine treatment options. Place a check mark next to each criterion you would like your physician to rely on when he or she makes recommendations about your treatment.
____1. The physician’s intuition (gut feeling) that a method will work
____2. What he or she has heard from other physicians in informal exchanges
____3. The physician’s experience with a few cases
____4. The physician’s demonstrated track record of success based on data he or she has gathered systematically and regularly
____5. What fits his or her personal style
____6. What is usually offered at the clinic
____7. Self-reports of patients about what was helpful
____8. Results of controlled experimental studies (data that show a method is helpful)
____9. What the physician is most familiar with
____10. What the physician has learned by critically reading professional literature
*From Gambrill, E., & Gibbs, L. (2017). Making decisions about intervention. In Criticalthinking for helping professionals: A skills-based workbook (4th ed., pp. 69–70). New York, NY: Oxford University Press.
Module 03
Course Project - Part 1
PATIENT REGISTRATION FORM
Practice – The People’s Clinic
Address – 1000 Town Square, Anytown Pennsylvania 54321
Phone – 555-741-8529
PATIENT INFORMATION
Patient – Mrs. Jane Doe
Married
Former name – Jane Smith
DOB – 01/01/1960
SSN - 123-45-6789
Address – 123 Main Street, Anytown Pennsylvania 54321
Phone – 555-987-6543
Occupation – Nurse
Employer – The People’s Hospital
Employer Phone – 555-456-7890
Doctor referral to clinic
INSURANCE INFORMATION
Jane Doe is responsible for payment
Primary insurance is Blue Cross Blue Shield
Subscriber – Jane Doe
ID – 123123123
Grp – 00550055
No secondary insurance
IN CASE OF EMERGENCY
Suzie Smith (sister)
Home – 555-567-8910
Work – 555-678-9012
.
Form_Event Medical and Rransportation Release [Child]
This document is a medical and transportation release form for a child participating in an event at Heritage Community Church. It collects the child's contact and health information, including any medical conditions, restrictions, allergies or medications. The parent gives permission for medical treatment if needed and assumes financial responsibility. The parent also approves of and releases the church from liability for transporting their child to and from event activities, acknowledging the risks of participation and transportation. The release is signed by the parent and expires 90 days after signing.
Consents medico legal case
This document provides information on medical consent forms, including what should be checked in cases of consent disputes, the model contents of a consent form, and a sample medical (non-surgical) consent form. A consent form should include details of the patient, diagnosis and planned treatment/risks/benefits, consent given by the appropriate party, witnesses, and extended consent for additional procedures if needed. The sample form outlines 17 points addressing the treatment plan, costs, decision-making, involvement of additional specialists, facilities, and contacting the primary doctors.
Medical Form
This document authorizes specific individuals to consent to any necessary emergency medical care for the parent or guardian's child(ren) during a given time period. It provides contact information for the child(ren)'s physician and hospital preference, as well as emergency contact numbers and insurance/medical assistance details. Medical information on the child(ren), such as allergies and immunization history, is also included.
MEDICO LEGAL CASES AND REPORTING.pptx
This document discusses medicolegal cases and reporting procedures for doctors. It defines a medicolegal case as one involving injury or illness requiring legal investigation. It outlines doctors' legal responsibilities to properly document and report such cases. Proper procedures are described for receiving cases, registering them, preparing records including findings and opinions, collecting samples, and storing documentation long-term. Fear of legal entanglements can cause doctors to avoid these cases, so understanding proper procedures is important.
Patient identification
This document discusses guidelines for proper patient identification. It emphasizes correctly identifying the patient before any procedures by checking multiple identifiers like name, date of birth, medical record number, etc. It provides dos and don'ts for staff, such as double checking identifiers on forms and samples, not taking multiple tasks at once that could mix patients up, and ensuring wristbands are legible and match the patient's file. Proper identification is crucial to avoid medication errors, transfusions for the wrong person, testing the wrong sample, and performing procedures on the wrong patient.
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- 1. Sanjeevani Multispeciality Hospital Plot No. 17, Rishi Park, Ambad Chowfully, JALNA 431203 Blood Transfusion Consent UHID : SHJ-124903 IPD Sr No : 17284 Patient Name : Miss. Ayesha Ajhar Shaikh DOA : 19-Sep-2023 Age /Sex : 15 / Female Time : 10:30:00 AM Address : Partur Jalna Relative : . Mobile : 9834274459 Relation : .. Under Care of : Dr. Shivdas Mirkad, Contact No. : 9834274459 Room : 306 - Semi Special Company : Self Dr.__________________________________________ has explained to me the Potential complications of transfusion of blood/ blood products which include the risk of transmission of infectious diseases such as Hepatitis ,HIV-AIDS and other bacterial and parasitic diseases, allergic and febrile reactions etc. I understand that all units of blood collected in the blood bank of Hospital are tested for antibodies to HIV1/ HIV2, Hepatitis C, Hepatitis B, Surface Antigen, Syphilis(Rapid Plasma Regain Test) and screened for Malarial Parasite; and that only units that are negative for these infectious diseases are released for transfusion; and that sterility checks and quality control procedures are regularly performed on samples of blood components. I also realize that no known test method can offer complete assurance that products derived from human sources will not transmit infection. I have read and understood this document and had a chance to clarify my doubts. If need arises for the transfusion of blood /products as part of my care ,I here by give consent to such transfusion. If patient is Unable to give consent the entire content may be explained to a relative, who signs mentioning the relationship to the patient. Patient Name:________________________________Signature:_________________Date:_____________Time:_____________ If patient is unable to sign, the name and relation of the person signing on his/her behalf Name:______________________________________Signature:__________________Date:_____________Time:_____________ Doctor's Name:_______________________________Signature:__________________Date:_____________Time:_____________ Witness on behalf at the Patient: Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________ Witness on behalf of the Hospital: Witness Name:_______________________________Signature:__________________Date:_____________Time:_____________ Interpreter's Statement: Specific language requirements (if any) Interpreter services required: [ ] Yes [ ] No I confirm that I have accurately interpreted the contents of this form, and the related conversation/s between the patient / person giving consent and the doctor. Interpreter's Name:_______________________________Signature:__________________Date:_____________Time:_____________