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HOSPITAL POLICY:
  60-08
SECTION:   Support Services
REVIEW RESPONSIBILITY:   Hospital Policy Committee
EFFECTIVE:   01/18/88
REVISE/REVIEW:   06/12/00
  
SUBJECT: Forms Management

PURPOSE:
To provide a systematic approach to the development, evaluation, and standardization of Vanderbilt University Hospital and Vanderbilt Medical Group (VUH/VMG) forms.

POLICY:
The Forms Committee is the body vested by VUH/VMG with the authority to oversee and set policy for VUH/VMG forms. Membership shall consist of representatives from the following areas: Forms Management, Informatics Center, Purchasing, Financial Management, Patient Care Centers, VMG Administration, Laboratories, and Medical Information Services. Other departments may be invited to send a representative at the Committee’s discretion. The Chair of the Committee shall be the Director of the Copy Center and Forms Management, who shall also set the meeting schedules.

The Forms Management section of the Copy Center (Forms Mgmt.) shall be agent charged with implementation of this policy. Oversight of the Medical Center’s forms shall be conducted in such a manner as shall: a) maximize standardization; b) eliminate unnecessary forms; c) control cost of recording, storing, and retrieving information; d) adequately address all legal, patient care, financial, and other issues that forms may involve.

SPECIAL INSTRUCTIONS:
 
A. Forms which must be submitted to Forms Management for approval are:
 
  1. Patient-related;
  2. Billing-related;
  3. Insurance-related;
  4. Consent forms;
  5. Forms involving the transfer of monies;
  6. Forms which will go into Medical Records;
  7. Forms which involve and/or are used by more than one department;
B. Information required on all forms:
 
  1. Each form approved will bear a form number, the assignment of which shall be coordinated by Forms Mgmt., and a revision date. Each form shall also be identified by department and title if at all possible.

  2. VUH/VMG forms shall be identified by one of the approved VUH/VMG logos as illustrated in the Vanderbilt University Graphics Standards Manual unless space forbids. Approved departmental logos are permissible where appropriate.
C. Copyright:
 
  1. Copyrighted items in general will not be reproduced without proper permission from the copyright holder. Certain limited exceptions to this rule may be permissible under copyright law, but the burden of use that the intended use is proper rests with the ordering department. Forms Mgmt. shall, however, reserve the right to seek legal advice and to refuse the request if it deems necessary.
D. Form files, stock, and returns
 
  1. Form files maintained by the Copy Center are VUH/VMG property. Original forms, approval documentation, artwork, and other materials necessary to the operation of the Copy Center and Forms Mgmt. will not be released to anyone within or outside Vanderbilt. Normally, however, any request for copies of these materials from within the Vanderbilt community will be honored. This will be at the discretion of Forms Mgmt.

  2. When a revision is requested on a form which is stocked in quantity, either at the Copy Center or an external forms vendor, the requesting department shall be responsible for buying out or arranging for the buying out of the existing stock. If the department does not wish to do this, the old stock will be depleted before the revision is implemented.

  3. Forms orders are normally non-returnable. Except in instances due to an error on the part of the Copy Center or an external forms vendor, returns will be allowed only at the discretion of the issuer. No returns will be allowed six (6) weeks after the order date.
E. Implementation
 
  1. The Forms Committee shall have the authority to develop reasonable guidelines for the implementation of this policy and to alter such guidelines from time to time as the structure and needs of VUH/VMG may change. These shall be binding upon all VUH/VMG departments under the terms of this policy.

  2. Current copies of these guidelines shall be made available by Forms Mgmt. on request.

DISTRIBUTION:
 Hospital Policy and Procedure Manual Holders


APPROVED: