NBS HBO Service Forms Site

Level 1 Hyperbaric Program: a hyperbaric program that offers a full scope of service for the hyperbaric patient.  They are typically hospital-based facilities that cover all recognized indications, including emergency life or limb threatening and are available for treatment of the emergent patient 24/7.  (This would be comparable to a Level 1 trauma center.)  "Extra credit" within this level could be earned by conducting formal training courses, clinical research, etc.

Level 2 Hyperbaric Program: a hyperbaric program that provides a reduced scope of service for the hyperbaric patient (does not treat emergency patients).  They are typically in the hospital setting and not available 24/7.  Generally, these programs provide high quality care to outpatients Monday - Friday and are not equipped or staffed for emergency indications. 

Should you need a form that is not readily available on the portal or if you would like to suggest a customized form for your center, please email your requests and suggestions to Stacy Handley, BSN, ACHRN, CWCN, CHT, Vice President of NBS. Your request will be reviewed, and you will be contacted.

NBS Support Contact Staff

  • NBS Support Team — PDF — Word

Compliance

  • Policy & Procedure Manual Level 1 — PDF — Word

  • Policy & Procedure Manual Level 2 — PDF — Word

  • Hospital Review Sign-off — PDF — Word

  • Staff Review Sign-off — PDF — Word

  • Operations Manual Level 1 — PDF

  • Operations Manual Level 2 — PDF

QAPI

  • 01 PI Intro Performance Improvement Plan — Word

  • 02 PI Appropriate Utilization of HBO Therapy — Word

  • 03 PI Data Review Form Appropriate HBO Utilization — Word

  • 04 PI Adverse Events — Word

  • 05 PI Data Review Form Adverse Sentinel Event — Word

  • 06 PI Medication Reconciliation — Word

  • 07 PI Data Review Form Medications Reconciled — Word

  • 08 PI Nutritional Status is Evaluated and Optimized — Word

  • 09 PI Data Review Form Nutritional Status is Evaluated and Optimized for Patients with Wound Related Conditions — Word

  • 10 PI Glycemic Control is Evaluated and Optimized for Diabetic Patients — Word

  • 11 PI Data Review Form Glycemic Control is Evaluated and Optimized for Diabetic Patients — Word

  • 12 PI Adherence to Current CDC Hand Hygiene Guidelines — Word

  • 13 PI Data Review Form Adherence to Current CDC Hand Hygiene Guidelines — Word

  • 14 PI Performance Improvement Plan Calendar — Word

  • 15 PI MONTHLY PERFORMANCE IMPROVE — Word

  • 16 PI QUARTERLY PERFORMANCE IMPROVE — Word

  • 17 PI ANNUAL PERFORMANCE IMPROVEMENT FORM — Word

QAPI

  • ICD-9 to ICD-10 Crosswalk HBO Indications Diagnosis Codes — PDF — Excel

  • Patient Financial Responsibility Statement to Physician — PDF — Word

  • Physician Super Bill Level 1— PDF — Word

  • Physician Super Bill Level 2 — PDF — Word

  • Medicare Billing Units — PDF — Word

  • Medicare Advance Beneficiary Notice (2013 Version) — PDF
    Medicare Advance Beneficiary Notice (2013 Version — Spanish) — PDF

  • Instructions for ABN Form Use (2013 Version) — PDF

  • ABN Sample for Labs — PDF

  • HBO Charge Master — PDF — Word

  • Daily Billing Summary Level 1— PDF — Word

  • Daily Billing Summary Level 2— PDF — Word

  • Physician Billing Coverage and Benefits Pre-Determination — Word

  • DAN Claim Form — PDF

  • National CMS policy: 20.5.2 Physician Supervision-Outpatient Therapeutic Services-eff 1-1-10 — PDF

Physician Charge Masters by State

  • Physician Participating Charge Master Listing 2019 Colorado — PDF — Word

  • Physician Participating Charge Master Listing 2019 Georgia Excluding Atlanta — PDF — Word

  • Physician Participating Charge Master Listing 2019 New York City Suburbs Long Island New York — PDF — Word

  • Physician Participating Charge Master Listing 2019 North Carolina — PDF — Word

  • Physician Participating Charge Master Listing 2019 Rest of New Jersey — PDF — Word

  • Physician Participating Charge Master Listing 2019 Pennsylvania Excluding Metro Philadelphia — PDF — Word

  • Physician Participating Charge Master Listing 2019 South Carolina — PDF — Word

  • Physician Participating Charge Master Listing 2019 Virginia — PDF — Word

Patient Chart

Basics

  • Patient History Form — PDF — Word

  • Education Checklist — PDF — Word

  • Treatment Record — PDF — Word

  • Patient Assessment & Treatment_Checklist — PDF — Excel

  • Prohibited Items — PDF — Word

  • Physician Orders Level 1 — PDF — Word

  • Physician Orders Level 2 — PDF — Word

  • Physician Order Critical Care — PDF — Word

  • Master Signature List — PDF — Word      

 

Consent

  • Emergent Treatment Consent — PDF — Word

  • Elective Treatment Consent — PDF — Word

  • Consent for Photography — PDF — Word

Clinical Notes

  • Physician Progress Notes Template — Word

  • Physician Notes — PDF — Word

  • Progress Notes — PDF — Word

Supplemental Chart Forms

  • Basic Care Plan — PDF — Word

  • Expanded Care Plan — PDF — Excel

  • Pre-Registration — PDF — Word

  • Medical Record Release — PDF — Word

  • Pre-Authorization — PDF — Word

  • Chart Checklist — PDF — Word

  • Ambulatory Summary — PDF — Word

  • Outpatient Acuity Scoring — PDF — Word

  • Medicine Administration Record — PDF — Word

  • Critical Care Flow Sheet — PDF — Word

  • Critical Care Checklist — PDF — Word

  • Repetitive Dive Worksheet — PDF — Word

  • Comprehensive Nursing Assessment — PDF — Word

  • Resuscitation Status — PDF — Word

  • Decompression Sickness Treatment Order & Record: US Navy TT5 — PDF — Word

  • Decompression Sickness Treatment Order & Record: US Navy TT6 — PDF — Word

  • Decompression Sickness Treatment Order & Record: US Navy TT9 — PDF — Word

Carbon Monoxide Screening

  • Manufacturer Instructions on Neuropsychological Testing — PDF

  • Neuropsychological Screening/Score Card — PDF

Discharge

  • Carbon Monoxide Discharge Instructions — PDF — Word

  • Carbon Monoxide Discharge Instructions — PDF Spanish

  • General D/C Instructions — PDF — Word

  • DCI One TX D/C Instructions — PDF — Word

  • DCI One TX D/C Instructions— PDF Spanish

  • DCI More Than One D/C Instructions — PDF — Word

  • DCI More Than One D/C Instructions — PDF Spanish

  • Physician Satisfaction Survey — PDF — Word

  • Patient Satisfaction Survey — PDF — Word

  • Reassessment of Radiation Cystitis-How to Tips — PDF — Word

  • Outcome Report — PDF — Word

  • Medical Record Transfer — PDF — Word

  • Patient Follow-up — PDF — Word

Non-compliant Patient

  • Notice of Potential Discharge for Non-compliance — PDF — Word

  • Final Notice of Discharge for Non-compliance — PDF — Word

Patient Education

Job Descriptions

General Education

  • Patient Ear Clearing Instructions — PDF — Word

  • Patient Ear Clearing Instructions — Word Spanish

  • Nutrition — PDF — Word

  • PE Tube Information — PDF — Word

  • PE Tube Information — PDF Spanish

  • Diabetic EZ Reference Tool — PDF — Excel

Bilingual Indication Info-sheets

  • Soft Tissue Radiation Necrosis — PDF

  • Osteoradionecrosis of the Mandible — PDF

  • Non-Healing Diabetic Wounds — PDF

  • Compromised Skin Flap and Skin Graft — PDF
    Compromised Skin Flap — Word
    Compromised Skin Graft — Word

  • Chronic Refractory Osteomyelitis — PDF _ Word

  • Necrotizing Soft Tissue Infections — PDF

  • Acute Carbon Monoxide Poisoning — PDF

  • Acute Traumatic Ischemic Injury — PDF

  • Acute Peripheral Arterial Insufficiency — PDF — Word

  • Acute Blood Loss Anemia — PDF

  • Gas Gangrene — PDF

  • Decompression Sickness — PDF

  • Cyanide Poisoning — PDF

  • Cerebral Arterial Gas Embolism — PDF

  • Actinomycosis — PDF

  • Frostbite — PDF

  • Intracranial Abscess — PDF

  • Thermal Burns — PDF

TCOM Forms

Monitor Inspection

  • Electrode Re-Membrane Log — PDF — Word

Site Charting

  • TCOM Assessment - 6 Site — PDF — Word

  • Lower Extremity Evaluation — PDF — Word

General Information

  • Electrode Re-Membrane Log — PDF — Word

TCOM Marketing

  • Marketing Letter — PDF — Word

  • Health Fair Screening — PDF

   Articles

  • Early Detection of Risk — PDF

  • Assessing Level of Amputation — PDF

Inspection

  • Daily Unit Inspection Level 1— PDF — Word

  • Daily Unit Inspection Level 2— PDF — Word

  • Weekly Chamber Check 3200 and E models — PDF — Word

  • Weekly Chamber Check H model — PDF — Word

  • Monthly Unit Inspection Level 1— PDF — Excel

  • Monthly Unit Inspection Level 2— PDF — Excel

  • Monthly Chamber Checks — PDF — Word

  • Patient & Chamber Ground Instructions — PDF

  • Monthly Environment of Care Rounds — PDF — Word

  • Monthly Medical Supply Checklist — PDF — Word

  • Semi-Annual Chamber Pressure Rate Verification Instructions — PDF — Word

  • Semi-Annual Chamber Pressure Rate Verification Log — PDF — Word

  • Semi-Annual Chamber Calibrated Pressure Verification — PDF — Word

  • End of Day Unit Checklist — PDF — Excel

  • Chamber Log Notes — PDF — Word

  • Cylinder Volume — PDF — Word

  • Chamber Specs — PDF — Excel

  • Hyperbaric 500A Ventilator Sterilization — PDF — Word1.2

  • Sechrist O2 Consumption Chart for 3200 and E Chambers — PDF

  • Sechrist O2 Consumption Chart for H Chambers — PDF

Safety

  • Authorized Use of Prohibited Materials — PDF — Word

  • GO List for Monoplace Chamber — PDF — Word

  • NO GO List for Monoplace Chamber — PDF — Word

  • Environmental Services — PDF — Word

  • Approved Chamber Disinfectants — PDF

  • Occurrence Report — PDF — Word

  • Equipment Maintenance Log — PDF — Word

  • Hospital Plum+ HBO IV Pump Manual — PDF

  • Zyno Z-800 IV Pump Manual - PDF

  • Safety Drill Scenarios — PDF — Word

  • Example Safety Drill — PDF — Word

  • Safety Drill Participation Logs

    • Cardiac Arrest — PDF — Word

    • Communication Failure — PDF — Word

    • Emergency Decompression — PDF — Word

    • Fire — PDF — Word

    • Pneumothorax — PDF — Word

    • Safety Door Pin Jam — PDF — Word

  • Wrist Ground Order Information — PDF — Word

  • Material Data Safety (MSDS)

  • Patient Ground Rod Instructions — PDF

Competency

  • HBO Competency Tracker— PDF — Word

  • Orientation Skills Competency Checklist Level 1— PDF — Word

  • Orientation Skills Competency Checklist Level 2— PDF — Word

  • Orientation Competency Quiz — PDF — Word

  • Annual Competency Checklist Level 1— PDF — Word

  • Annual Competency Checklist Level 2— PDF — Word

  • Staff Daily Duties Checklist — PDF — Word

  • Critical Care Competency — PDF — Word

  • Critical Care Meds Review List — PDF — Word

  • Expected Pediatric Vital Signs — PDF — Word

  • Teed Scale Poster — PDF

  • Teed Scale Descriptions — PDF

  • Physician Proctor/Preceptorship — PDF — Word

  • Ventilator Orientation and Bi Annual Competency — PDF — Word

Required Competencies

  • Gas Handling Procedure Competency — PDF — Word

  • Individual Emergency Decompression Competency — PDF — Word

Primary Q & A

  • Physician Chart Audit Checklist — PDF — Word

  • Staff Chart Audit — PDF — Word

  • Physician Chart QA Spreadsheet — Excel

  • Staff Chart QA Spreadsheet — Excel

Secondary Q & As

  • Barotrauma — PDF — Word

  • Hypoglycemia — PDF — Word

  • Oxygen Toxicity — PDF — Word

Nurse Education

  • Nurse Education Tri-Fold Color Brochure — PDF — Word

  • Power Point Presentation: "HBO; A Nursing Overview" — PowerPoint

Hyperbaric Chamber Clearance

  • What are 510k Clearance and Premarket Approval — PDF — Word

  • Code of Federal Regulations Title 21
    Recognized Consensus Standards for NFPA and ASME PVHO — PDF

  • Premarket Notification
    Sechrist 3200 #K950386 — PDF
    Sechrist 3300E # K052713 — PDF
    Sechrist 3600E Line Extension — PDF

  • Sechrist 33, 36, 41 H Series Chambers #K100268 — PDF​

Hyperbaric Chamber Acrylic Inspection

  • Reading Material — PDF — Word

  • Exam — PDF — Word

  • Exam — Evaluator Copy — PDF — Word

  • Competency Validation — PDF — Word

  • Competency Validation — evaluator copy — PDF — Word

  • Sample Document — cylindrical window — PDF — Word

  • ASME PVHO-2 Window Forms — PDF

  • Effect Of ASME PVHO-1 Safety Standard On The Design Of Viewports In Pressure Vessels — PDF

HBO Certification

  • National Board of Diving & Hyperbaric Medical Technology (NBDHMT)

  • Undersea & Hyperbaric Medical Society (UHMS)

Job Descriptions

  • Hyperbaric Technician — PDF — Word

  • Hyperbaric Registered Nurse — PDF — Word

  • Hyperbaric Nurse Manager — PDF — Word

  • Unit Clerk —PDF — Word

  • Safety Director — PDF — Word

  • Wound Care & HBO Medical Staff Roles and Responsibilities — PDF — Word

  • Supervision FAQs for NPs & PAs — PDF — Word

  • HBO Credential Resource Guide — PDF