Nota bene: First CIUSSS standardized medical record form

New, standardized inpatient prescription form for all CIUSSS hospitals and long-term care facilities
New, standardized inpatient prescription form for all CIUSSS hospitals and long-term care facilities

Hospital inpatient and long-term care staff, take note: when you fill out a prescription for your patient or resident, you will all soon be reaching for the same, new form.

Two standardized forms for inpatient prescriptions (one for in-hospital, another for discharge) were developed by the Interim Chief of Pharmacy for CIUSSS West-Central Montreal, Eva Cohen, for inpatient facilities throughout the network. The transition to the new forms will take place in the upcoming months. They will replace the existing, site-specific versions presently used by doctors, nurses and pharmacists once that inventory has run out.

“The forms have a fresh look and share the same template and logo, in keeping with the new CIUSSS standards for medical file forms,” says Chantal Desmarais, Medical Records Services Coordinator. Ms. Desmarais points out that there is one variation on the forms, and that is the name of the site, which is pre-printed, to spare staff from having to write it out each time.

Standardized medical forms are introduced to CIUSSS facilities to enhance the quality and consistency of health information within the network. The task of reviewing the standards on medical record forms, then creating and distributing the updated forms, lies in the hands of a single, multidisciplinary group, the Committee for the Standardization of Medical File Forms (to learn more about the committee, read Keeping in Good Form in the August 360).

Ms. Cohen also reviewed and standardized the distribution of the copies of these forms (NCR), as follows:

Pharmacy form copies
Hospital inpatient prescription Original in medical file
Yellow copy to Pharmacy
Discharge prescription Original to the patient
Pink copy in medical file

To learn more about the creation or revision procedures of forms in users’ medical files, visit the new Medical Archives intranet page at Administrative Departments > Information Management > CIUSSS Medical Records.

Contact the Committee for the Standardization of Medical File Forms at medical.forms.ccomtl@ssss.gouv.qc.ca or via Lotus Notes, at Medical Record Forms.

 

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