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I. Requesting a form
A new or revised form which falls under the policy must
be requested through the use of the Forms Management Questionnaire (MC 0723).
If the form will enter the patient chart, the request can be sent directly to
Medical Records, except under the special procedures for ED and PHV outlined
below. ED, PHV, and all non-chart forms should be sent to the Copy Center.
Requests sent to the Copy Center must be accompanied by a requisition to cover
revision costs.
Forms which are used only within one department are not controlled under
the policy and do not need to be documented or approved. These will, however,
be numbered and placed in file by the Copy Center if requested by the department.
Please note that departments are encouraged to make economical use of the hospital's
resources in maintaining their filing and recordkeeping systems and Forms Management
may make suggestions to that end.
II. Medical Record/Consent forms
All forms which enter the patient chart must be approved by
Medical Records. Please note that proper format must be observed for approval.
All forms which enter the patient chart must conform to the following guidelines:
- Size: 8.5" x 11"
- ¾" inch binding margin at left, including back side if double-sided;
- 5-hole punch;
- Imprinter block area at upper right, 2 1/8" x 3 ½" in size, front only if double-sided;
- Signature line at bottom or on last page of multi-page items.
(Templates for this layout in Microsoft Word format are available here:
Front side or Back side.)
Other points that should be noted:
- One page of a multi-page form cannot be placed in the chart alone, because it would lack the signature line;
- For good reproduction after being placed in the chart, paper should be white, and ink should be black;
- Sizes other than 8.5" x 11" will require special permission from Medical Records before production.
Patient-care related consent forms must be approved by both Medical Records and the Office of General Counsel.
Medical Records shall submit the item for approval by the Office of General Counsel.
Note on special Medical Record approvals:
CASE MANAGEMENT –
Medical Records has delegated to this area responsibility for
approving two types of forms—collaborative pathways and teaching tools.
The signature of a responsible Case Mgmt.
official on the Forms Questionnaire certifies to Forms Management
that this process has been completed.
PSYCHIATRIC HOSPITAL —
Inasmuch as Medical Records has its own staff stationed at this facility,
it is empowered to approve its own forms, including arranging for legal
approval where needed. The signature of
a responsible Medical Records official at PHV on the Forms Questionnnaire
certifies to Forms Management that this
process has been completed.
III. Encounter Forms
Creation and revision of these forms are under the supervision of VMG. Clinics requiring
new or revised forms must submit all data to VMG Administration in a specified Excel format. VMG will then
coordinate with the Department of Finance, Compliance Office, and any other areas to ensure the accuracy of
the forms. Once the form is complete and approved, VMG will release the file to the Copy Center for printing
and ordering by users.
IV. Prescription Pads
PLEASE NOTE - written prescriptions for TennCare
patients must now be on tamper-resistant paper. The guidelines
below are supplemented by further information on this issue posted at the link
below
VUMC
Tamper-Resistant Pad Page
A personalized prescription pad meeting good therapeutic standards as
well as all applicable state and federal laws will be made available by the Copy
Center. This design is uniform and institution-wide. Variations from this
standard will be permitted if they can be shown to assist in the patient care
process. Such variations must be approved by the Pharmacy before implementation.
The Office of Graduate Medical Education will be responsible for ordering
these pads for all housestaff. All personalized prescription pads must be
returned to the Office of Graduate Medical Education at the end of training.
Other physicians may order at their own discretion.
NOTE: Since these forms are printed 4 per page, there is a minimum order of 4
pads, and it is requested that larger orders be made in multiples of 4—8 pads,
16 pads, 24 pads, etc.
SPECIAL NOTE ON CERTIFIED NURSE PRACTITIONERS: Pursuant to Tennessee
law and recommendations by the VUMC Pharmacy, pads for these employees must meet
the following guidelines:
- the name, address, and phone number of the supervising physician and the
nurse practitioner;
- the nurse practitioner must sign both his/her name and the name of the
supervising physician;
- space must be provided for DEA numbers assigned to the nurse practitioner to be
shown.
Language outlining these requirements must be printed on each nurse
practitioner's prescription pads.
V. Typesetting forms for printing by the Copy Center
Using departments may typeset their own forms if desired. However, all requirements for approval
and formatting laid down in the Forms Policy and in these guidelines must be observed. In addition, they must meet the
following standards:
- If submitted electronically, they must be prepared in a software format compatible with the Copy Center's files.
Preferred formats are Word for Windows, Excel, CorelDraw, or PageMaker.
- If submitted on paper, the user must first contact Forms Mangement to obtain an MC number for the form. This
must be printed by the user on the form in a size and style compatible with established practice, i.e., in an inconspicuous
part of the item, in a typeface no larger than 8 points and preferably sans-serif and italic. The month and year of the
revision should appear in parentheses after the number.
- In all cases, an adequate margin of at least 1/4" must be allowed at each edge of the paper.
VI. Web Forms
Web forms in general are subject to the same approval process as paper forms. Determination
of which forms may be made available on the web page will be made by Forms Management with the advice of the Forms
Committee. Suggestions from users are welcome. Currently, forms to be posted on the Forms Management website must
meet the following guidelines:
- Paper consumption less than 5,000 per year;
- No need for complex finishing, such as padding, punching, or sequential numbering;
- Do not involve issues or activities making them liable to misuse, such as medication prescribing, purchasing,
legal consents, etc.
VI. Translation
The Office of Patient Affairs will coordinate translation of any forms which must be presented
in languages other than English in order to fulfill VUMC’s responsibilities to its patients and to comply with all
applicable laws. Such forms and other documents include but are not limited to the following:
- Consent forms;
- Any statement of patient rights and responsibilities;
- Forms recording the patient’s diagnosis, prognosis, treatment, and/or discharge plan.
New and revised items falling into these categories will be referred by Forms Management
to Patient Affairs for consideration for translation.
Translated text must be approved by Patient Affairs and transmitted by that office
directly to Forms Management. It is generally expected that alternate language text will be presented
on the same page with English text in order to facilitate use of the form by both patient and caregiver,
and Forms Management will design with this in mind.
Translated items will be filed and may be ordered
according to the following system:
An alternate language form will share the same MC# as its English-language counterpart.
It will be distinguished by a three-letter extension on the end of the number which
will indicate the language used in the form. These extensions are: |
