Patient Signature Forms Committee

Purpose and Scope

The Patient Signature Forms Committee is charged with approving the development of new documents (paper and electronic), condensing the existing catalog of forms, editing, and making recommendations for all forms incorporated into the electronic health record requiring a patient signature. This includes, but not limited to, consents, notifications, and/or acknowledgements to comply with applicable regulations and ensure readability.

Functions include:
• Reviewing all forms requiring a patient signature prior to build or inclusion in the medical record with an emphasis on organizational efficiency, consolidation to minimize inventory, secure legal review, and to ensure appropriate document and medical record indexing standards are met.
• Reviewing research documents that require patient signature and have been approved to be part of the medical record.
• Ensuring compliance with documentation standards and defining the required workflow associated with use of patient completed and/or signed documents. Patient signature includes both wet signature and/or electronic signature.
• Developing and maintaining processes to manage form creation with a focus on reasonable standardization, version tracking and potential electronic creation.
• Confirm appropriate reading level and usability of the form.
• Coordinate with information technology (IT) for technology enhancements, interface, and form development while ensuring all channels of data collection contain the same approved documentation elements used during downtime processes, are consistent with VUMC existing or proposed policy and comply with regulatory/statutory standards and policies.
• Provide input regarding the technical infrastructure required to support the implementation of compliant electronic documents, including:
• Data storage
• Technology and hardware
• Ensure consistency in content between paper and electronic versions.

Reporting

The Patient Signature Forms Committee is a subcommittee of the Health Record Executive Committee under the auspices of the Medical Executive Committee.

Meetings

The Patient Signature Forms Committee meets monthly, or as often as needed to accomplish the work.

Patient Signature Forms Committee Membership Representation
Co-Chairs (Executive Leadership Adult Ambulatory Operations and HealthIT Associate Chief Medical Information Officer)
Health Information Management
Primary HIM Forms Management Support Staff
Health IT HIM Team
VUH/VCH Administration
Patient Education
Ambulatory Leadership
MHAV Representative
Clinicians
Office of Legal Affairs—ex Officio, non-voting
Ad Hoc Members
(As needed for content review, workflow analysis, or as requested by the Committee)
Accreditation & Standards
Customer Care Team (HealthIT)
Nursing Informatics Services
Office of Compliance and Corporate Integrity
Peri-Op/ OR Administration
Quality, Safety & Risk Prevention
Regional Hospital and Clinic Representation
VUMC Admitting

Approved by the Health Record Executive Committee: September 2023
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