Electronic Documentation Templates Support ICD-10-CM/PCS Implementation. Appendix B: Request Form for Note Title and Templates

Date submitted:

Date needed:

Contact Information:
(include name, e-mail address; department; telephone number)

Type of Request (circle one):
Note Title Template

If revision, include original note title or template title.

If revision, should the original title or template be deactivated?

Proposed Title:

Proposed Template and Associated Note Title:

Purpose or Description of Template:

Guidelines for Completion of Template:

Does another organization have a copyright on all or portions of the template? (Explain in detail)

TESTING:

Who will test the note title or template (provide contact info)?

Estimated time frame for testing:

Additional changes to the note or template after testing:

APPROVALS: (include individual(s) and date)

Consensus of Users:
yes or no

Department Head:

Service Chair:

Quality Management for Pertinent Accrediting Requirements:

Committee responsible for program (i.e. Infection Control):

Clinical Informatics:

Health Information Management Services (HIMS):

Legal Counsel:

Health Information Management Committee:

TRAINING:

Who will train the user?

Training dates and audience:

ANNUAL REVIEW:

Usage:

Revision needed:
Yes or No

Comments:

If revised, notification of requestor or department:
(name and date)

Continue activation:
Yes or No

Comments:

If deactivated, notification of requestor or department:
(name and date)

Return to practice brief.