Clinical Service Guide Forms and Teaching Sheets

Local Health Department Medical Abbreviations

General

• CH-3A Service/Progress Notes
• CH-12 Form Instructions
• CH-12  Misc. Screening and Lab Tests (Rev. July 2015)
• CH-23 Authorization for Release/Acquisition of Patient Information (Rev. July 2006)
• CH-23 Spanish
• CH-23 Instructions
• EM-1 Emergency Flow Sheet
• HHS-117 Telephone Order Form Instructions
• HHS-117 Telephone/Verbal Order
• HP13 Initial Adult
• HP13 Initial Adult - Spanish
• H&P 13 Initial (Pediatric) Rev. July 2011 (Spanish)
• H&P 13 Initial Instructions (Rev. July 2014)
• H&P 14 Interval (Adult) Rev. June 2017 (Spanish) (PDF)
• H&P 14 Interval (Pediatric) Rev. July 2011 (Spanish)
• H&P 14 Interval Instructions (Rev. July 2014)

Cancer 

• ACH-16 Breast Cancer Screening Form
• ACH-40 Improving Health for Women (English) (Spanish)
• ACH-58 Kentucky Women's Cancer Screening Program Data Collection Form
• WH-58 Cancer Screening Form (Rev. Jan. 2019)
• WH-58 Minimum Data Elements Training Manual
• ACH-100 Mammogram Log (Rev. Jan. 2011)
• ACH-259 (Rev. Jan. 2011) Pap Log
  

Diabetes

• DSMT-1 Pre/Post Class Feedback Form

Domestic Violence

• DV/SA-1 Domestic Violence/Sexual Assault Documentation Form

Family Planning

• ACH-264-B (Rev Jan 2016) Consent for Deferring a Physical Exam
• ACH-264-B Spanish (Revised 2016)
• ACH-280 Consent for IUD Insertion or Removal (Rev 2016)
• ACH-280 Consent for IUD Insertion Spanish
• ACHI-9 Healthier Lifestyles for Family Planning (July 2011)
• ACHI-9 Healthier Lifestyles Spanish
• ACHI-12 DES Exposure (Jan 2016)
• ACHI-12 DES Exposure Spanish
• BC-1 Resupply Visit Form (Rev June 2016)
• BC-1 Resupply Visit Form Instructions
• FP-1 Consent Form Instructions
• FP-1 Consent Form (Rev Jan 2016) 
• FP-1 Consent Form Spanish (Rev Jan 2016) )
• FP-2 Depo-Provera Consent
• FP-2 Depo-Provera Consent, Spanish
• FP-3 Consent for Insertion of Implant
• FP-3 Consent for Insertion Implant Spanish
• FP-4 Consent for Removal of Implant
• FP-4 Consent for Removal of Implant Spanish
• FPS-1 Family Planning H&P-Female Client
• FPS-1 Family Planning H&P-Female Client (Spanish)
• FPS-1 Family Planning H&P-Female Client Form Instructions
• PT-1 Pregnancy Test Visit Form
  
• PT-1 Pregnancy Test Visit Form Instructions (Rev 2016)

Sterilization: 

• Sterilization Consent Form
• Sterilization Consent Form, Spanish

Growth Charts

• Automated Growth Charts
• Growth Chart Instructions
• MCH-1 Boys birth to 36 months
• MCH-2 Girls birth to 36 months
• MCH-3 Boys 2 to 20 years
• MCH-4 Girls 2 to 20 years

Health Risk Assessments

• ACH-90 Baby, birth to 12 months
• ACH-90 Spanish
• ACH-91 Child 12 months to 6 years
• ACH-91 Spanish
• ACH-92 Child 7 thru 10 years
• ACH-92 Spanish
• ACH-93 Adolescents 11 thru 20 years
• ACH-93 Spanish
• ACH-94 Adults 21 and older, all pregnant, all FP patients
• ACH-94 Spanish
• HRA Instructions (Rev. Jan. 2008)

Hepatitis C

• HCV-1
• HCV-2
• HCV-3

HIV

• HIV Test Form EPID 396
• Adult Case Report Form (ACRF)
• Pediatric Case Report For (PCRF)

 

 Immunization

• CH-2A Immunization Record
• CH-2A Instructions
• IMM-1 Instructions
• IMM-1 Informed Consent for Vaccines
• IMM-1 Informed Consent for Vaccines, Spanish
• What Parents Need to Know - Religious Exemption to Immunizations

• Certificate of Immunization Status (EPID 230)
• Immunization Declination form (EPID 230-A)

Lab

•   PHLOK-1 Laboratory Personnel    Orientation and Training
• PHLOK-2 Laboratory Personnel Competency Assessment
• PHLOK-3 Sample Clinic Authorized Procedure
• PHLOK-4 Lab Tasks Checklist
• PHLOK-5 Sample QA Worksheet

 

Lead

• Lead 1 Case Management
• Lead 2 Visual Investigative Home Visit (Rev. July 2018)
• Lead 3 Follow-up Home Visit

Oral Health

• Fluoride Supplies packing slip-order blank (July 2006)
• KIDS SMILES Order form (July 2006)
• MSDS-1 Nafrinse Drops
• MSDS-2 Nafrinse Tablets
• MSDS-3 Fluoride Varnish
• MSDS White Varnish Omni
• OH-9 Consent for Fluoride (English and Spanish)
• OH-10 Home Water Sample (Jan. 2005)
• OH-10 Spanish (Jan. 2005)
• OH-11 Kids' Smiles (personal record)
• OH-11 Spanish
• OH-12 Dental Screening/Exam Form for School Entry
• OH-13 Consent Rework for Fluoride Varnish
• Prevent Tooth Decay Labels
• Prevent Tooth Decay Labels, Spanish

Perinatal Hepatitis B

• EPID-394
• EPID-395
• PHBP-1
• PHBP-2
• PHBP-3
• PHBP-4
• PHBP-5
• PHBP-6
• PHBP-7
• PHBP-8
• PHBP-9

Prenatal

• ACOG Form A (2003)
• ACOG Form B (2003)
• ACOG Form C (2003)
• ACOG Form D (2003)
• ACOG Form E
• ACOG Form F
• ACOG Form G
• Discharge Postpartum Form
• ACH-282 Prenatal home visit
• ACH-283-A Postpartum Home Visit
• ACH-283-B Postpartum Neonatal Home Visit
• PN-1 Consent Form Screening for Cystic Fibrosis (April 2013)
• PN-1 Consent Form Screening for Cystic Fibrosis, Spanish
• PN-2 Pregnancy Health Risk Screen (Rev July 2017)
  • KY Moms Referral Form
  • KY Moms Service Map
• PN-3 Exercise in Pregnancy (April 2013)
• Epid-399 Perinatal Hep B Prevention Form for Infants
  

Reportable Diseases

• EPID 200 Kentucky Reportable Disease Form (Sept. 2014)

Sexually Transmitted Diseases

• STD-1 Sexual History and Physical Exam Form (Rev. March 2014)
• STD-1 Instructions
  
• STD1 (6-17) -Spanish
  

Tobacco

• T-1 Smoking Counseling Sheet
• T-2 Freedom From Smoking Documentation

Tuberculosis

• TB-1 Infection Form (Rev. July 2018)
• TB-2 Contact Investigation (Rev. July 2018)
• TB-2a Contact Roster Instructions
• TB-2b Contact Investigation Summary
• TB-3 Report of TB Screening (Rev. July 2018) (Spanish)

• TB-4 TB Risk Assessment Form (Rev. July 2018)
• TB-4a Instructions for TB Risk Assessment
• TB-4b Additional Instructions
• TB-5 Candidates for Treatment of Latent Tuberculosis Infection (LTBI) Rev. July 2018
• TB14 KY V-DOT (Rev. July 2018)

• TB-14a Consent Form for Video-Directly Observed Therapy (V-DOT)

• TB-15 Informed Consent for DOT
• TB-16 TB Case Management
• TB-16a Nurse Guidelines for Tuberculosis Case Management
• TB-16b TB Case Management Clinical Pathway Checklist
• TB-17 DOT Record Initial and Continuation
• TB-17a DOT Record Initial
• TB-17b DOT Record Continuation
• TB-17c DOT Tracking Record (Missed Doses)
• TB 17d Clinic DOPT Record Continuation
• TB-18 Bacteriology Report
• TB-19 TB Surveillance Report
• TB-20 TB Clinic Follow-up Visit
• TB-21 TB Clinic Referral Form
• TB-22 TB Clinic Physician/APRN Orders
• TB-23 TB Chronic Medication List
• TB-24 TB Clinic Progress Notes
• TB-25 TB Clinic Education Counseling Record
• TB-25a Electronic References
• TB-26 TB Clinic Social Service Assessment
• TB-26a TB Clinic Social Service Progress Notes
• TB-26b TB Clinic Social Services Care Plan
• TB-27 Activities for Providing DOT for Outreach Workers
• TB-28 Prioritization of Contacts
• TB-29 TB Disease Treatment Cards
• TB-30 LTBI Treatment Cards  
• TB-31 Incentives and Enabler Request
• TB-32 LHD TB Monthly Report

• TB H&P-13 TB Clinic Initial Health Assessment/History/Exam (March 2018)

• Procedure for TST

 

Teaching Sheets General

• ACH-10 Improving Health for Men
• ACH-40 Improving Health for Women (July 2018)
• ACH-40 Spanish (Rev. July 2018)
• Breast Self Exam vs Breast Self Awareness (optional)
• Breast Self Exam vs Breast Self Awareness - Spanish
• Mammogram Benefits and Risks (optional)
• Mammogram Benefits and Risks - Spanish
• GPEM-1 Safe Options for Home Needle Disposal
• GPEM-2 Proper Disposal of Prescription Drugs
• Guide to Lowering Blood Pressure
• PAM-ACH-265 Pregnancy Tests (Jan. 2010)
• PAM-ACH-265 Pregnancy Tests, Spanish
• Patient Satisfaction Survey
• Patient Satisfaction Survey, Spanish

Domestic Violence

• Service Providers and Contact Information
• Safety Plan Pamphlet

Family Planning

• ACHI-9 Healthier Lifestyles for Family Planning (Jan 2016)
• ACHI-9 Spanish (July 2011) 
• ACHI-12 DES Exposure (April 2006)
• FPEM-1 Family Planning Methods (Rev Jan 2016) 
• FPEM-1 Family Planning Methods, Spanish (Rev Jan 2016)
• FPEM-2 Emergency Contraceptive Pills (Rev Jan 2016)
• FPEM-2 Emergency Contraceptive Pills, Spanish (Rev Jan 2016)
• FPEM-3 Abstinence (Rev Jan 2016)
• FPEM-3 Abstinence, Spanish (Rev Jan 2016)
• FPEM-4 Combined Oral Contraceptive Pills (Rev Jan 2016)
• FPEM-4 Combined Oral Contraceptive Pills, Spanish (Rev Jan 2016)
• FPEM-5 Progestin-only Pill (Rev Jan 2016)  
• FPEM-5 Progestin-only Pill, Spanish (Rev Jan 2016)
• FPEM-6 Depo-Provera
• FPEM-6 Depo-Provera, Spanish
• FPEM-7 Implant
• FPEM-7 Implant, Spanish
• FPEM-8 Ortho Evra Patch
• FPEM-8 Ortho Evra Patch, Spanish
• FPEM-9 NuvaRing 
• FPEM-9 NuvaRing, Spanish
• FPEM-10 Intrauterine Device
• FPEM-10 Intrauterine Device, Spanish
• FPEM-13 Natural Family Planning
• FPEM-13 Natural Family Planning, Spanish
• FPEM-14 Diaphragms
• FPEM-14 Diaphragms, Spanish
• FPEM-15 Male Condoms
• FPEM-15 Male Condoms, Spanish
• FPEM-16 Female Condom Revised (Rev 2016) 
• FPEM-16 Female Condom, Spanish (Rev 2016)
• FPEM-17 Spermicidal Cream (Rev 2016)
• FPEM-17 Spermicidal Cream, Spanish (Rev 2016)
• FPEM-18 Cervical Cap (Rev 2016)
• FPEM-18 Cervical Cap, Spanish (Rev 2016)
• FPEM-20 Common Vaginal Infections (Rev June 2016)
• FPEM-20 Common Vaginal Infections, Spanish (Rev June 2016) 

Sterilization: 

• Female Sterilization Fact Sheet
• Female Sterilization Fact Sheet, Spanish
• Male Sterilization Fact Sheet
• Male Sterilization Fact Sheet, Spanish

Hepatitis C

• HCV Links to Teaching Sheets

HIV

• CHFS-EPI What You Should Know About HIV/AIDS (Dec. 2011)
• CHFS-EPI What You Should Know About HIV/AIDS (Dec. 2011) Spanish

Lead

• MCH-25 What is Lead? (July 2013)
• ACH-25 What is Lead, Spanish (Rev. March 2003)

Oral Health

• OHEM-3 Fluoride Varnish 
• OHEM-4 BrushUp Tips
• OHEM-4 BrushUp Tips, Spanish
• OHEM-5 First Aid for Dental Injury
• OHEM-6 Keeping Your Smile
• OHEM-7 Mouthguard
• OHEM-8 Diabetes and Gum Disease 
  

Points to Remember

• MCH-12 Your Newborn to 1 Month Old (Rev. July 2013)
• MCH-12 Your Newborn to 1 Month Old, Spanish (Rev. June 2013)
• MCH-13 Your Baby 2 to 9 Months Old (Rev. July 2013)
• MCH-13 Your Baby 2 to 9 Months Old, Spanish (Rev. June 2013)
• MCH-14 Your 12 Month Old (Rev. July 2013)
• MCH-14 Your 12 Month Old, Spanish (Rev. June 2013)
• MCH-15 Your 15 to 18 Month Old (Rev. July 2013)
• MCH-15 Your 15 to 18 Month Old, Spanish (Rev. June 2013)
• MCH-16 Your 2 or 3 Year Old (Rev. July 2013)
• MCH-16 Your 2 or 3 Year Old, Spanish (Rev. June 2013)
• MCH-17 Your 4 Year Old (Rev. July 2013)
• MCH-17 Your 4 Year Old, Spanish (Rev. June 2013)
• MCH-18 Your 5 or 6 Year Old (Rev. July 2013)
• MCH-18 Your 5 or 6 Year Old, Spanish (Rev. June 2013)
• MCH-19 Your 7 or 8 Year Old (Rev. March 2013)
• MCH-19 Your 8 Year Old, Spanish (Rev. June 2013)
• MCH-20 Your 9 or 10 Year Old (Rev. March 2013)
• MCH-20 Your 9 or 10 Year Old, Spanish (Rev. June 2013)
• MCH-21 When You Are 11 to 14 (Rev. March 2013)
• MCH-21 When You Are 11 to 14, Spanish (Rev. June 2013)
• MCH-22 When You Are 15 to 17 (Rev. March 2013)
• MCH-22 When You Are 15 to 17, Spanish (Rev. June 2013)
• MCH-23 When You Are 18 to 21 (Rev. March 2013)
• MCH-23 When You Are 18 to 21, Spanish (Rev. June 2013) 
  

Prenatal

• Safe Sleeping for Baby
• Safe Sleeping for Baby (Spanish)
• KIDS NOW Plus Brochure (Rev. Jan. 2015)
• KIDS NOW Plus Map (Rev. Jan. 2015)
• MCH-8 Healthier Lifestyles for the Pregnant, Breastfeeding and Postpartum Woman
• PAM-ACH-8 Spanish
• MCH-PN-T1 First Trimester Prenatal Care
• MCH-PN-T2 Second Trimester Prenatal Care
• MCH-PN-T3 Third Trimester Prenatal Care
• MCH-PN-T4 Fourth Trimester Postpartum Care 
  

Tobacco

• TEM-1 Coping With Withdrawal Symptoms (Rev. July 2015)

Quality Assurance Tools Lead

• Medical Record Review

Pediatrics

• Well Child Medical Record Review

School Health

• Medical Record Review

Tuberculosis

• Program Audit Tool

Women's Health

• QA - QI Policy Requirements
• QA - QI Tool
• QA - QI Instructions
• QA - QI Chart Code List