The TSWF Nursing Services AIM form is intended to be used by nurses and clinical support staff in adult PCMH clinics. The form is not designed for use in pediatric and non-PCMH immunization clinics.

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Nursing Services Recent Changes

  • 15 changes for May-Aug 2018 update
  • Updated Depo-Provera procedure note with revised DEPO-PROVERA procedure note on Meds 2 Tab
  • UTI Dysuria Procedure on the Procedures 2 Tab
    • Additional clinical clue “AF Dysuria CSSP does not require HCG testing to be performed unless medically indicated”
    • Added clinical cue for ICD & CPT = ICD-10: R30.0: Dysuria; ICD-10: Z71.89: Other Specified Patient Education; CPT: 81000: Dipstick with microscopy; CPT: 81002: Dipstick without microscopy
    • Added complaint to S/O: Female pt c/o of the following: ” [ ] Dysuria (pain/burning)”
    • Added Exclusion Criteria: Mark ‘Y’ for YES, ‘N’ for NO in the boxes below
      “[ ] Is one or more UTI symptoms lasting more than 7 days?”
      “[ ] Pregnant or possibly pregnant?”
      “[ ] Provider notified of exclusion criteria?”
    • Added to A: Labs to be ordered: ” [ ] N/A”
    • Added to P: “[ ] Provider notified of lab orders/results”
  • Links Updated:


  • Created June 2014
  • Standardize documentation
  • Intended use in adult PCMH clinics

The TSWF Nursing Services form was created in early 2014 and went live on the AHLTA Enterprise in June 2014. It was created to standardize the nursing services documentation of administered immunizations, medications, nursing procedures, and patient education & counseling performed at the point-of-service. The form’s intended use is acute, routine, or other scheduled patient visits in adult PCMH clinics.

Form Lead

TSWF-Nursing Services Form Lead
Scot Ario

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