Sample Forms

Note:

• Pertinent workflows are now in Connect Care: all order sets, PRAM assessment, discharge prescriptions and asthma education checklist (under Pediatric Asthma Education). 
• Reference documents continue to be available through DATA Group. Do not use sample forms.

Emergency Department and Urgent Care

• Order Set
• Assessment Form
• Discharge Prescription and Short-Term Plan
  • AHS
  • Covenant

• Order Set
• Assessment Form
• Discharge Prescription and Short-Term Plan
  • AHS
  • Covenant

Reference Tools

Note: All documents are available through DATA Group Do not use samples

Algorithms

Emergency Department & Urgent

• Brochure
• Poster
• Reference Card

Inpatient

• Brochure
• Poster
• Reference Card

PRAM Scoring Tool

Available in pocket-size cards:

• Emergency Department and Urgent
• Inpatient

• Alberta Asthma Action Plan
  • Fillable Form, available in English, French, Punjabi and Traditional Chinese
  • Printable Form, available only in English
• Alberta’s Child and Teen Asthma Tools
• Alberta’s School Kit
• Asthma Society of Canada
• My Health Alberta
• National Asthma Org (Australia) - Device Technique Videos
• The Lung Association – AB & NWT

Videos are best viewed in Chrome or Firefox | Legal Disclaimer

Alberta Childhood Acute Pathways

(www.albertachildhoodpathways.com)

• Online Training Modules (all disciplines; eligible for CME credit)

Health Professional Videos

Featuring Kathy Courtney, RRT, CRE

1. Basics of Asthma (13 minutes)
   • Pathophysiology
   • Goals of asthma treatment
   • Factors in asthma control
   • Types and purpose of medications
2. ACAP Overview Part I (11 minutes)
   • Rationale for ACAP
   • PRAM scoring
   • Basic overview of ACAP forms
   • Protocols for mild ED/UCC
   • Self-management education resources
3. ACAP Overview Part II (9 minutes)
   • Protocol for moderate
   • Asthma Education Checklist
   • Protocol for severe
   • Rationale for spacers
4. ACAP Overview Part III (11 minutes)
   • Using ACAP Forms
   • Detailed review of orders, assessment, Rx Discharge, ED Checklist
   • Tailoring education to patients’ needs
   • Nuances of accurate diagnosis
   • Basic overview IP Protocol
5. Medication Administration Techniques Part I (13 minutes)
   • MDIs and Spacers
   • EpiPen *Recall for Allerject – no longer available as of January 2016*
6. Medication Administration Techniques Part II (10 minutes)
   • Nebulizer (including large volume), Spray, EpiPen

Emergency Physician Videos

Featuring Dr. David Johnson, Project Lead and Senior Medical Director for MNCY SCN

1. Assessment – (6 minutes)
2. Asthma Education – (5 minutes)
3. Initial Therapy – (11 minutes)
4. PRAM Score – (10 minutes)
5. Why MDIs & Spacers – (10 minutes)
6. Pathway Introduction – (11 minutes)

Inpatient Physician Video

Featuring Dr. Michelle Bailey, MSc., MD, FRCP(C) Section Chief, Hospital Pediatrics, Department of Pediatrics

1. Pediatric Asthma (approx. 50 minutes)