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Request for Approval of New or Revised Medical Record Form

The destination of each request submitted is to SPH Medical Records and SPH Graphics Center. Each form request will be introduced to the SPH Forms Committee for review and finalizing. Upon Committee approval, forms will be presented to SPH CMO for final approval prior to publishing.

You will receive a confirmation email following request submission. If you do not receive a confirmation email, please check your request content to ensure *Required Fields* have been accurately completed, and then resubmit your request. Please submit one request for each form, the upload feature only allows a single file at a time. You may upload a draft copy of new/revised forms (preferably Word). Scan pdf or standard pdf files of edits/revisions of an existing form or proposed can be uploaded.

New or revised forms may take 4-6 weeks or longer for completion. This depends on the complexity of the form or the discovery of clinical issues/findings. The requestor will be notified of the expected delay beyond the normal processing time frame.

Your name (Requester/Author)

Your SPH email address:

Your phone number (or extension)

Your department (or discipline)

What is your director's name?

Did your department director review/approve this form?

Yes

This form is a:

New Form

Please attach the proof of the proposed form.

Pilot Form

Please include an attachment explaining the length of the pilot (in weeks).

Revised Form

Please attach a copy of the current form and a proof of the proposed form.

Combination of Forms

Please attach a copy of the current form and/or a proof of the proposed form.

Form title:

Form number (if a revision):

What is the intended purpose and use of this form?

Does this form reflect current knowledge in the field?

Yes

Is there another active form for the same purpose or procedure?

Yes

If yes, please describe why the existing form will not work.

Does the form comply with all specifications listed in the attached policy?

Yes

If no, please explain why.

Is this a multipart form?

Yes

If yes, include a list of the distribution for each part below.

Example: white copy/Medical records, yellow copy/Patient.

Who is responsible for completing this form?

For example, a physician, respiratory therapist, or nurse.

What is the estimated monthly usage of this form?

For example, the number of copies.

New forms only: How is this information currently being documented?

Revised or combination forms only: Will existing stock be used up? Please answer below yes, no, or N/A. Please also state the reason for the revision or combination of the forms.

Please list any medical departments and/or provider groups that will be affected by the proposed form.

Please also note the date that these groups reviewed and accepted the contents of the form.

Please attach form documentation here.