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61. Tips for Transfer | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/transfer-tips.html
    February 01, 2021 - Tips for Transfer Resource: Tips for Transfer (PDF, 245 KB)  This form is to be completed … The completed form should travel with the resident to provide ED staff with essential information.

62. Hospital Transfer Cover Sheet | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/hospital-cover-sheet.html
    February 01, 2021 - Hospital Transfer Cover Sheet Resource: Hospital Transfer Cover Sheet (PDF, 358 KB)  This form … The completed form should travel with the resident to provide Emergency Department staff with essential

63. Staffsafetyassess (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/staffsafetyassess.doc
    June 02, 2025 - Staff Safety Assessment Purpose of this form: This form is designed to tap into your experience at the … How to complete this form: Provide as much detail as possible when answering the two questions below. … When to complete this form: This form can be filled out by any health care provider at any time. … At a minimum, health care providers should complete this form semiannually.

64. TeamSTEPPS Measurement Tools | Agency for Healthcare Research and Quality
    www.ahrq.gov/teamstepps-program/resources/tools/index.html
    January 01, 2024 - Measurement Tools Browse the measurement tools used in TeamSTEPPS: ASTD Coaching Self-Assessment Form …  (PDF, 161 KB) This form will guide you through a self-evaluation exercise that will assist you in … TeamSTEPPS Coaching Feedback Form (PDF, 181 KB) During the scripted coaching practice exercise, the … observer uses this form to document the demonstrated competencies of the designated coach. … TeamSTEPPS Training: Evaluation Form (PDF, 354 KB) This course evaluation form for a two-day TeamSTEPPS

65. 113-Staff-Safety-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/113-staff-safety-assessment.docx
    October 01, 2024 - AHRQ Safety Program for MRSA Prevention Staff Safety Assessment ICU & Non-ICU Purpose of this form: This … form is designed to tap into your experience to determine what risks are present in your unit that have … How to complete this form: Provide as much detail as possible when answering the questions below. … When to complete this form: This form can be filled out by any healthcare provider at any time. … At a minimum, healthcare providers should complete this form semi-annually.

66. Appendix B29: Engineer Inspection List | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb9txt.html
    December 01, 2017 - Forms and Training Materials (Appendix Contents) Appendix C. … Falls Engineer Instructions Text Description of Form For the person doing the inspect … : Label this form and fill it out in the same way as for the Nursing Inspection List. … Safety Problems in Common Areas With Common Equipment: Image of Form

67. Tracking and Improving Screening for Colorectal Cancer Intervention | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/crctoolkit/index.html
    March 01, 2023 - Electronic Record Review 4.a-1 Introduction Letter to Patients With Instructions for Completing SEA Form … Spanish) 4.a-2 Screening Eligibility Assessment (SEA) Form  (incl. … Spanish) 5.a-1 Master Patient Database Elements 5.d-1 Chart Audit Review Form 6.a-1 Feedback Form … for Stool Test Positive 6.a-2 Feedback Form for Stool Test Negative 6.b-1 Feedback Form for CDE … 6.a-2 Feedback Form for Stool Test Negative         6.b-1 Feedback Form for CDE     Assessment        

68. Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care-2/facilitator-guide.html
    July 01, 2023 - In addition are links to two TeamSTEPPS documents, the coaching self-assessment form and the coaching … feedback form. … The coaching self-assessment form and feedback form are tools for self-improvement. … The feedback form can guide coaches on how to deliver feedback more effectively. … (PDF, 253 KB) TeamSTEPPS coaching feedback form (PDF, 103 KB)

69. 066-Staff-Safety-Assessment (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/066-staff-safety-assessment.docx
    April 01, 2025 - Services For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries Purpose of this form … : This form is designed to tap into your experience to determine what risks are present in your clinical … How to complete this form: Provide as much detail as possible when answering the questions below. … When to complete this form: This form can be filled out by any member of the healthcare team at any time … At a minimum, healthcare team members should complete this form semiannually.

70. Choosing an Intervention and Measuring Change | Agency for Healthcare Research and Quality
    www.ahrq.gov/antibiotic-use/long-term-care/improve/intervention.html
    June 01, 2021 - The Staff Safety Assessment Form and the Learning from Antibiotic-Associated Adverse Events Form … The Monthly Data Collection Form can help track antibiotic use, urine cultures, and Clostridioides … Staff Safety Assessment Form (DOCX, 330.3 KB) Learning From Antibiotic-Associated Adverse Events Form … (DOCX, 226.7 KB) Intervention Worksheet  (PDF, 157.4 KB) Monthly Data Collection Form (XLSX, 345.5

71. Heart Health Now Advancing Heart Health in NC Primary Care Consent Form (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/consent-form-nc.pdf
    June 02, 2025 - Heart Health Now Advancing Heart Health in NC Primary Care Consent Form Heart Health NOW Advancing …  Form and facilitate the work of a quality improvement (QI) team in your practice  Meet with your … Page does not require timed responses Navigation links Passed Navigation links are not repetitive Forms … Rule Name Status Description Tagged form fields Passed All form fields are tagged Field descriptions … Passed All form fields have description Alternate Text Rule Name Status Description Figures alternate

72. Medication Management: Procedure: Engaging Your Patient To Create a Medication List (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/medication-mgmt-staff-procedure.pdf
    June 02, 2025 - Using the Medication List form, go through the prescription medications one by one. a. … Check whether the medication is expired and note that on the Medication List form. d. … Check on the form whether the patient is taking the medication as prescribed. f. … Page does not require timed responses Navigation links Passed Navigation links are not repetitive Forms … Rule Name Status Description Tagged form fields Passed All form fields are tagged Field descriptions

73. Labor and Delivery Unit Safety Issues Worksheet for Senior Executive Partnership | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/worksheet.html
    July 01, 2023 - Health care providers and senior leader(s) How to complete this form: Provide as much detail as possible … When to complete this form: It should be completed at least semiannually.

74. Planning for Sustainability | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/enhanced-recovery/planning.html
    June 01, 2023 - Use your performance data and the Gap Analysis and Goal Setting Form to identity measures to focus on … and Barriers to Sustaining Gains in Enhanced Recovery (DOCX, 240 KB) Gap Analysis and Goal Setting Form

75. Tracking-Measuring-Data-Facilitator-Guide (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/tracking-measuring-data-facilitator-guide.docx
    June 01, 2021 - form during the reporting month. … Slide 4 Monthly Data Collection Form SAY: This slide shows the data collection form available on … The instructions are included on the top of the form, or on the first page if the form is printed. … This portion is on the second page of the printed form. … We will go through each element of the form in more detail.

76. SOPS Research Datasets | Agency for Healthcare Research and Quality
    www.ahrq.gov/sops/databases/research-datasets.html
    May 01, 2024 - SOPS De-Identified Data Research Abstract Form (Word, 38 KB)—Researchers requesting de-identified data … must submit a completed form outlining the proposed use of the data. … Sample SOPS De-Identified Data Research Abstract Form (PDF, 304 KB)—Shows the form completed with sample … obtaining hospital-identifiable data must submit a completed Hospital-Identifiable Research Abstract Form … data must submit a completed form outlining the proposed use of the data.

77. 2. Description of the Intervention (continued) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreen2a.html
    April 01, 2018 - ideally involves two components: (1) conducting electronic record reviews, and (2) reviewing returned SEA forms … We also allowed more time for receiving completed forms. … Our Experience We sent the appropriate feedback forms to the practices at several interim points during … However, we did not receive any completed forms. … We contacted the practice manager at several points regarding collecting the CDE feedback forms without

78. Candidate Measure Submission Form (CPCF) | Agency for Healthcare Research and Quality
    www.ahrq.gov/policymakers/chipra/cpcf-form6.html
    December 01, 2013 - Candidate Measure Submission Form (CPCF) CHIPRA Pediatric Quality Measures Program (PQMP) The … CHIPRA Pediatric Quality Measures Program (PQMP) Candidate Measure Submission Form (CPCF) was approved

79. Candidate Measure Submission Form (CPCF) | Agency for Healthcare Research and Quality
    www.ahrq.gov/policymakers/chipra/cpcf-form7.html
    December 01, 2013 - Candidate Measure Submission Form (CPCF) CHIPRA Pediatric Quality Measures Program (PQMP) The … CHIPRA Pediatric Quality Measures Program (PQMP) Candidate Measure Submission Form (CPCF) was approved

80. Candidate Measure Submission Form (CPCF) | Agency for Healthcare Research and Quality
    www.ahrq.gov/policymakers/chipra/cpcf-form14.html
    December 01, 2013 - Candidate Measure Submission Form (CPCF) CHIPRA Pediatric Quality Measures Program (PQMP) The … CHIPRA Pediatric Quality Measures Program (PQMP) Candidate Measure Submission Form (CPCF) was approved