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Circular 91-13


DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Indian Health Service
Rockville, Maryland 20857

Refer to: OHP/MRB

INDIAN HEALTH SERVICE CIRCULAR NO. 91-13

Effective Date:  December 11, 1991

PATIENT CARE FORMS COMMITTEES

  1. PURPOSE.  The purpose of this circular is to establish Patient Care Forms Committees at Headquarters, Area, and service unit levels to ensure that Indian Health Service (IHS) policies, objectives, procedures, and responsibilities are adhered to throughout the IHS.  This circular may be used by tribal contractors as a guidance.

  2. BACKGROUND.  Extensive interdisciplinary review must be conducted at all service levels prior to the finalization of any official IHS patient care form proposed for development, revision, and/or discontinuation.  The vast variation in programs at different IHS sites, the uniqueness of certain programs, the multiple use of different forms by various categories of health practitioners and administrative personnel, medico-legal and medical record requirements, and the wide range of personal preferences necessitates the establishment of this policy.

  3. OBJECTIVES.

    1. To provide for an orderly, effective, and efficient mechanism for developing new or revised IHS patient care forms for use at the various levels of the IHS.

      NOTE:  The Interagency Committee on Medical Records (ICMR) is responsible for reviewing all health care related Standard Forms (SF) to ensure quality, uniformity, and adequacy of health care records of the Federal Government.  The ICMR is responsible for developing new and revised medical SF and requesting cancellation of and exceptions to existing medical SF.  General Services Administration (GSA) is responsible for promulgating and approving medical SF.

    2. To establish an organized hierarchy of Patient Care Forms Committees at Headquarters, Areas, and service unit levels which will review and monitor the development, revision, and discontinuation of IHS patient care forms.

    3. To ensure an interdisciplinary approach is followed in reaching the objectives.

    4. To ensure that legal requirements for Federal forms management and control and Privacy Act regulations and procedures are complied with, in accordance with GSA regulations.

  4. RESPONSIBILITY.  At all administrative levels the Privacy Act Coordinator, the Medical Records Consultant/Director/Supervisor, and the Forms Management Officer shall be included as members of each Forms Committee.

    1. Headquarters shall have an interdisciplinary Patient Care Forms Committee.

    2. The Associate Director, Office of Health Programs or designee is responsible for establishing the Headquarters Patient Care Forms Committee.

    3. Each Area Office shall have an interdisciplinary Patient Care Forms Committee.

    4. The Area Chief Medical Officer or designee is responsible for establishing the Area Patient Care Forms Committee and for monitoring its actions.

    5. The Service Unit Director is responsible for establishing the interdisciplinary review protocol for the service unit.

    6. Each service unit hospital and/or health center shall have an interdisciplinary review protocol established through the Medical Records Committee for evaluating new, revised or discontinued IHS patient care forms proposed by the staff of the service unit and/or health center.  Service units without hospitals shall perform forms committee review functions through the use of staff of their quality assurance programs.

      NOTE:  The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires that each Medical Records Committee of each facility be accredited and include representation from the medical staff, medical records, nursing, and administration.

  5. PROCEDURES.

    Service Unit

    1. Individuals or specific disciplines shall present the need of a new form, revision or discontinuation of any IHS patient care form to the Service Unit Patient Care Forms Committee.

      NOTE:  To ensure proper data management and integrity, the service unit must assess the impact of information collection and dissemination for all proposed new, revised, or discontinued IHS patient care forms.

      When approved by the Service Unit Patient Care Forms Committee the proposed IHS patient care form is to be submitted to the Area Patient Care Forms Committee for review, approval, and submission to the Headquarters Patient Care Forms Committee for similar action.

    2. Non-automated proposed or revised IHS patient care forms may be utilized at the service unit on a trial basis before being forwarded to the Area for further formal action.  Each proposed IHS patient care form shall be evaluated by an established protocol during the trial period.

      NOTE: Public Health Service (PHS) policy defines trial period as one printing cycle (6 months).

      If a new automated IHS patient care form or an existing automated IHS patient care form is to be modified or changed, this may require systems analysis, programming efforts, software testing, computer capacity, etc.  A manual trial period must be instituted in preparation for the automation of the form.  During the trial Period, the Office of Information Resource Management, IHS, will participate in the analysis, assessment, and recommend the final automation approval. Automated forms will be subject to the alpha/beta test criteria under the Resource and Patient Management System.

    3. All local temporary IHS patient care forms shall be reviewed at the end of the trial period for need or appropriateness.

      NOTE:  The local temporary form shall be approved by the Service Unit Patient Care Forms Committee and assigned a local temporary form number utilizing a number control system.  The temporary form number shall be printed on all temporary forms.  The expiration date of the temporary form is not to exceed the last day of the trial period.

    4. Overprinting:  Overprinting means the printing of pertinent identical entries (e.g., agency name and address, accounting codes and organization codes) in a captioned area on a form.

      Designing a new form, such as Nursing Pediatrics Admission Assessment, and copying it on an existing form, such as Progress Note, is not overprinting; this constitutes designing a new form.  Thus, any IHS patient care forms that are being overprinted must follow the new form procedures described in 5 A., B., and C.

      The Department of Health and Human Services (HHS) Forms Management Manual, Chapter 3-50-40 B. regulations state; "Forms may be overprinted with the OPDIV or Regions' name or identification.  Also, spaces which contain information of a constant nature or spaces which are not to be used, may be overprinted.  This overprinting is at the OPDIV or Regions' discretion but should be performed only for, and limited to, quantities that are cost-effective.  Occasionally, upon written request, the Department Forms Management Officer may give permission for local printing when conditions warrant.  All overprinting will be at the expense of the requester."

    5. Duplication of an official IHS patient care form is discouraged.  The IHS patient care forms must be available in adequate quantities at all times.

      Official IHS patient care form: A form which has received clearance and approval by the service unit or Area or Headquarters Patient Care Form Committees.

    Area Office

    1. Determines appropriateness of the service unit requests to reject or refer request to specific disciplines for further review, comment or development.

    2. Determines impact of the request for use based on the need, appropriateness, format, and design for the Area.

    3. Approves IHS patient care forms for temporary use in the Area and recommends IHS patient care forms for IHS-wide use.

    4. The Area Patient Care Forms Committee reviews suggested drafts of the new or revised IHS patient care form or requests for discontinuation of the forms from service unit, Area, and Headquarters personnel.

    5. Sends approved drafts of the new or revised IHS patient care forms or recommends discontinuation of the IHS patient care forms to the Headquarters Patient Care Forms Committee, Office of Health Programs, Rockville, Maryland.

    Headquarters

    1. Ensures that all IHS patient care forms are regularly reviewed, as to need and appropriateness.

    2. Reviews proposed drafts of new or revised IHS patient care forms or requests for discontinuation of IHS patient care forms submitted by the Area Patient Care Forms Committee or Headquarters disciplines or personnel.

    3. Determines need, appropriateness, format, and design of the proposed form for IHS-wide use.

    4. Refers and distributes the final draft of new or revised IHS patient care forms for review and comments to appropriate Headquarters staff and Area Office Patient Care Forms Committees.

    5. Reviews comments and recommendations received from Area and Headquarters disciplines, and if necessary modifies the form and submits the final IHS patient care form for appropriate action.

    6. Informs Area or Regional Supply Service Center of new, revised, and discontinued IHS patient care forms.

    7. Assists the Headquarters Forms Management Officer with the functional responsibility of clearances, form layout and design, printing and distribution, specifically, by defining the technical specifications of new and/or revised IHS patient care forms to the extent that there is little or no difficulty in obtaining required clearances from appropriate authorities, i.e., HHS and PHS. Also, assists in the distribution and receipt of new and/or revised IHS patient care forms when requested to do so or when an emergent situation exists.

  6. SUPERSESSION.  This circular supersedes IHS Circular No. 82-3, Patient Care Forms Committee, dated April 13, 1982, in its entirety.

/Everett R. Rhoades, M.D./
Everett R. Rhoades, M.D.
Assistant Surgeon General
Director, Indian Health Service

Circular Exhibit 91-13-A

INDIAN HEALTH SERVICE (IHS) PATIENT CARE FORMS - CLEARANCE REGISTER

This is not and exact replica.
For a copy of the exact form please contact your Area Directives, Delegations, and Control Officer or
the Management Policy and Internal Control Staff at 301-443-2650

Number Page________ of________
FORM NUMBER TITLE OF IHS
PATIENT CARE FORM
EDITION DATE
AND
CLEARANCE CODE
ACTION CODE FORM
USERS
  

  

  

  

  

CEARANCE CODE: N = New Form
R = Revision, previous editions obsolete
C = Revision, Previous edition usable
O = Form has been canceled
ACTION CODE 1 = Discontinue immediately
2 = Discontinue on date indicated
3 = Deplete existing stocks, do not reprint
4 = Deplete existing stocks before issuing
5 = Dispose of existing stock on receipt of revision
6 = Other (Specify _________________________

NOTE:  From the time a new or revised form appears on the clearance register it will take approximately 30-60 days for non specialty forms (A/O printing cycle) or 40-90 days for specialty forms (J/J printing cycle) before it is available for distribution to the regional supply center.

FORM USERS:  For forms distribution, the specific branch/program will be notified by the regional supply center when the forms are received at the appropriate regional supply center.


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