|
Device Deployment Order:
|
|
|
Provider's name or department ordering
|
Date of Order
|
|
Condition Being Monitored:
|
|
|
Conditions
• • •
|
|
|
Device Identification:
|
|
|
Scale
|
Heart Rate
|
|
BP
|
|
|
Date of Device Delivery:
|
|
|
Patient Education:
|
|
|
Education Provided
|
Date of Patient Education:
|
|
Understanding
|
Skill
|
|
Notes:
|
|
|
Informed Consent:
|
|
|
Consent
|
Date of Consent:
|
|
Method of Consent:
• • •
|
|
|
HIPAA Compliance:
|
|
|
Privacy & Data security
|
HIPAA privacy rights
|
|
Notes:
|
|
|
Documented by:
|
|
|
Medical Assistant
|
Incident to (on premise Dr)
|
