Get University Of North Carolina Hospitals Mim 1054 2013-2025

Filling out the University of North Carolina Hospitals MIM 1054 form online is a crucial step in the therapeutic phlebotomy process. This guide will provide you with a clear and comprehensive overview of each section of the form, ensuring accurate completion for effective patient care.

Follow the steps to complete the MIM 1054 form accurately.

1. Press the 'Get Form' button to access the therapeutic phlebotomy order form and open it in your editing interface.
2. Fill in the date and time fields at the top of the form accurately. This information is essential for record-keeping.
3. In the first section, indicate the volume of blood to be removed by filling in the blank next to 'Remove _________ mL of whole blood.' Specify the frequency of repeat phlebotomy if the hemoglobin level exceeds the specified threshold.
4. State the goal of therapeutic phlebotomy in the provided space. This information is vital for treatment objectives.
5. Confirm that no fluid replacement will occur, or select 'Administer Normal saline 500 mL IV x 1' if applicable.
6. List the laboratory work to be drawn pre-phlebotomy or at the specified intervals. Include a complete blood count (CBC) along with any additional required tests such as ferritin or iron profile.
7. Provide the date of the last History and Physical examination in the designated space. Remember to attach a copy if not available on UNC WEBCIS.
8. Select one diagnosis from the provided options, ensuring it aligns with the medical necessity for the tests ordered.
9. Certify that the diagnosis codes support the tests ordered by checking the appropriate statement regarding the urgency of treatment.
10. Sign and date the form in the spaces provided for both the provider's signature and the transcribed and checked sections.
11. Review all filled sections to ensure accuracy, then save changes, and proceed to download, print, or share the form as needed.

Complete your documents online with confidence and accuracy today!