Learn about the latest revisions to clinical decision support tools.

What’s happening? 

The Student Practice team would like to inform students and faculty instructors about revisions to a number of Clinical Decision Support Tools (CDST), which may impact their practice areas. The revisions are as follows and are in immediate effect.

Seamless perinatal care – clinical protocol 

  • Seamless perinatal care – clinical protocol 
  • Revisions

    Revised Seamless Perinatal Care Referral – Form

    • Client information has been moved to the top of the form, followed by the referring provider’s information; this will make it easier to see the name of the person being referred, as well as their general demographic information.
    • Outcome of the referral section has been removed. This also provides more space overall to make the form more readable.

    New Outcomes of Seamless Referral – Form

    • An ‘outcome of referral’ form has been created to support clear communication back to referring partners. The antenatal transition team will assign a seamless lead, who will then complete this form within two weeks. This form will be faxed to the referral source and primary care provider (if not the same person). The outcome of referral form identifies who the seamless lead is and their contact information. 

    Updated processes

    • Updated to include roll out in all delivery hospitals
    • Changes to the role of Public Health Nurse (PHN): PHNs are to fax the “Notification of PHN follow up” letter to:
      the antenatal transition team , and  
      primary care provider.


    • When there is a significant change to the client’s plan of care the PHN is to notify:
    • The primary care provider, and
    • The antenatal transition team.


  • Impacted programs, professions, networks

    Maternal, Child, Infant & Youth (MICY) programs, Social Work, and Public Health programs.

Medication prescribing, directive/order processing, administration and documentation - clinical protocol 

  • Medication practice
  • Revisions

    • This document has been revised to reflect the latest Accreditation Canada’s Medication Management required high priority standards such as:
    • Requirements for vaccine documentation: brand name, lot #, expiry date, and body site
    • Multidose vial dedicated for a single patient. Beyond use date labelling
    • Medication Administration Record (MAR) to bedside: for routine precaution, removal of wiping down of horizontal surface requirement as long as horizontal surface is visibly clean.
    • Transdermal patch labelling. Not supported by manufacturer to write directly on patch so document on MAR and apply sticker to patch.

    • Links to related resources have been all updated to reflect current version.

  • Impacted programs, professions, networks

    Prescribers/Nursing/Dieticians/Infection Prevention and Control/Medical Imaging/Residential Care and Assisted Living Services/Respiratory Therapy/Speech-Language Pathology, and Student Practice

Documentation – Clinical Policy

  • Documentation clinical policy

  • Revisions
    • Appendix A: Child Life Specialist Specific Documentation Requirements
    • Appendix added which delineates the specific documentation requirements for Child Life Specialists.
    • Appendix B: Dietician Specific Documentation Requirements
      The College of Dieticians of British Columbia has revised their title for students to Dietician Student (replacing Dietetic Intern)
    • Appendix C: Nursing Specific Documentation Requirements
    • In accordance with the newly formed British Columbia College of Nursing Professionals (BCCNP) bylaws, the class of registrants for Registered Nurses, Registered Psychiatric Nurses, and Licensed Practical Nurses has been revised to include temporary and provisional registration statuses (replacing interim and limited).
    • Updates to nursing related references to BCCNP (replacing College of Licensed Practical Nurses of British Columbia, College of Registered Nurses of British Columbia, and College of Registered Psychiatric Nurses of British Columbia).

  • Impacted programs, professions, networks

    All individuals who document in the patient health record in Fraser Health, including both paper-based and electronic documentation.

Why is this important? 

Fraser Health considers the patient experience in all parts of the health system. This includes the development and revision of policies, Clinical Decision Support Tools, forms, and Pre-Printed Orders. Our goal is to provide quality care that is sensitive and responsive to patient needs, preferences, and beliefs.

How will this impact students and faculty instructors? 

Students and faculty instructors who are completing student placements in Fraser Health are expected to apply any necessary changes in their practice to ensure that patients, clients, and residents continue to receive safe and quality care. Students and faculty instructors can only access these CDSTs via FH Pulse when they are on a Fraser Health computer on a Fraser Health site.


Please contact the Student Practice Team.

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