FORMS APPROVAL FORM HCH 708

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FORMS APPROVAL FORM HCH 708 Powered By Docstoc
					                JOHN DEMPSEY HOSPITAL                                                                         HCH# (To be assigned by HIMFC)
                UNIVERSITY OF CONNECTICUT HEALTH CENTER
                HEALTH INFORMATION MANAGEMENT FORMS COMMITTEE
                FARMINGTON, CT 06030
                FORMS APPROVAL FORM                                                                           DATE SUBMITTED:
                           HCH #708 REV. 10/92, 3/03



                                                                               F      Form Sponsor:
T     Judy Buxton, Health Information Management
O     MC-2925                                                                  R      Department: ________________ ___                      Ext: ___ ___
                                                                               O
                                                                                      Location:                                   MC:
                                                                               M


1.    NAME OF FORM


2.    ARE THERE ANY ABBREVIATIONS USED ON THIS FORM THAT ARE                       IF YES, PLEASE INDICATE ABBREVIATION AND MEANING:
      NOT LISTED ON THE APPROVED JDH ABBREVIATION LIST IN THE
      ADMINISTRATIVE MANUAL?     YES     NO

WHEN CONSIDERING QUESTIONS 3 AND 4, ASK YOURSELF WHO WILL HAVE BLANK COPIES, WHO WILL WRITE ON IT, WHO WILL READ IT, WHO WILL KEEP IT.


      BRIEFLY STATE THE USAGE OF THIS FORM

3.




      WHO ARE THE USERS OF THE FORM?                 HAVE THEY BEEN CONSULTED?           YES      NO

4.




5.    IF THIS FORM WILL BE PLACED IN THE IN-PATIENT MEDICAL RECORD,
      PLEASE INDICATE WHICH TAB/SECTION IT WILL BELONG IN:
      WILL THIS FORM REPLACE ALL OR PART OF ANOTHER FORM?              YES   NO IS THIS FORM A REVISION OF AN EXISTING FORM?          YES    NO
      IF YES TO EITHER QUESTION, PLEASE INDICATE NAME AND HCH# OF THE FORM(S) BEING REPLACED OR REVISED:
6.



      PLEASE CHECK ALL THAT APPLY:

7.           Single Copy             Multiple Copy          Snap Out           Continuous         Color         Packaging (qty/pkg)

             Padding                 NCR Carbon             Double-Sided       Size               Collating     Folding
      WHAT IS THE ANNUAL ESTIMATED USAGE OF THIS FORM?

8.                 copies per year



            FOR HEALTH INFORMATION MANAGEMENT FORMS COMMITTEE COMPLETION
     APPROVED              RECOMMENDATIONS (see below)                         STOCK IN MEDICAL WAREHOUSE?                 YES          NO

Recommendations:




NOTE: If HIMFC conditionally approves with recommendations, a final draft must be sent to HIMFC prior to ordering.

Y:forms/forms,lists/forms approval form.doc

				
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