Sync template from atomicqms-style deployment
This commit is contained in:
64
Forms/FRM-001-Document-Change-Request.md
Normal file
64
Forms/FRM-001-Document-Change-Request.md
Normal file
@@ -0,0 +1,64 @@
|
||||
# Document Change Request Form
|
||||
|
||||
| Form ID | FRM-001 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Request Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Request Date | |
|
||||
| Requested By | |
|
||||
| Department | |
|
||||
|
||||
## Section 2: Document Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Document Number | |
|
||||
| Document Title | |
|
||||
| Current Revision | |
|
||||
|
||||
## Section 3: Change Description
|
||||
|
||||
### Type of Change
|
||||
- [ ] New Document
|
||||
- [ ] Revision to Existing Document
|
||||
- [ ] Document Obsolescence
|
||||
|
||||
### Description of Change
|
||||
*(Describe the proposed change in detail)*
|
||||
|
||||
|
||||
|
||||
|
||||
### Reason for Change
|
||||
*(Explain why this change is needed)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 4: Impact Assessment
|
||||
|
||||
### Affected Areas
|
||||
- [ ] Training Required
|
||||
- [ ] Other Documents Affected
|
||||
- [ ] Process Changes Required
|
||||
- [ ] Validation Impact
|
||||
|
||||
### List Affected Documents
|
||||
|
||||
|
||||
## Section 5: Approvals
|
||||
|
||||
| Role | Name | Signature | Date |
|
||||
|------|------|-----------|------|
|
||||
| Requester | | | |
|
||||
| Document Owner | | | |
|
||||
| Quality Assurance | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-001 Rev 1.0*
|
||||
91
Forms/FRM-003-CAPA-Form.md
Normal file
91
Forms/FRM-003-CAPA-Form.md
Normal file
@@ -0,0 +1,91 @@
|
||||
# Corrective and Preventive Action (CAPA) Form
|
||||
|
||||
| Form ID | FRM-003 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: CAPA Identification
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| CAPA Number | |
|
||||
| Date Initiated | |
|
||||
| Initiated By | |
|
||||
| CAPA Owner | |
|
||||
| Target Closure Date | |
|
||||
|
||||
## Section 2: Classification
|
||||
|
||||
### Type
|
||||
- [ ] Corrective Action
|
||||
- [ ] Preventive Action
|
||||
|
||||
### Source
|
||||
- [ ] Customer Complaint
|
||||
- [ ] Internal Audit
|
||||
- [ ] External Audit
|
||||
- [ ] Process Deviation
|
||||
- [ ] Nonconforming Product
|
||||
- [ ] Management Review
|
||||
- [ ] Other: ____________
|
||||
|
||||
### Priority
|
||||
- [ ] Critical (5 business days)
|
||||
- [ ] Major (15 business days)
|
||||
- [ ] Minor (30 business days)
|
||||
|
||||
## Section 3: Problem Description
|
||||
|
||||
*(Describe the nonconformity or potential nonconformity)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 4: Immediate Containment
|
||||
|
||||
*(Actions taken to contain the immediate impact)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 5: Root Cause Investigation
|
||||
|
||||
### Investigation Method Used
|
||||
- [ ] 5 Whys
|
||||
- [ ] Fishbone Diagram
|
||||
- [ ] Fault Tree Analysis
|
||||
- [ ] Other: ____________
|
||||
|
||||
### Root Cause Determination
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 6: Corrective/Preventive Actions
|
||||
|
||||
| Action | Responsible | Due Date | Status |
|
||||
|--------|-------------|----------|--------|
|
||||
| | | | |
|
||||
| | | | |
|
||||
| | | | |
|
||||
|
||||
## Section 7: Effectiveness Verification
|
||||
|
||||
| Criteria | Method | Result |
|
||||
|----------|--------|--------|
|
||||
| | | |
|
||||
|
||||
Verification Date: ____________
|
||||
Verified By: ____________
|
||||
|
||||
## Section 8: Closure
|
||||
|
||||
| Role | Name | Signature | Date |
|
||||
|------|------|-----------|------|
|
||||
| CAPA Owner | | | |
|
||||
| Quality Approval | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-003 Rev 1.0*
|
||||
56
Forms/FRM-006-Audit-Checklist.md
Normal file
56
Forms/FRM-006-Audit-Checklist.md
Normal file
@@ -0,0 +1,56 @@
|
||||
# Internal Audit Checklist
|
||||
|
||||
| Form ID | FRM-006 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Audit Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Audit Number | |
|
||||
| Audit Date | |
|
||||
| Area/Process Audited | |
|
||||
| Lead Auditor | |
|
||||
| Auditee(s) | |
|
||||
|
||||
---
|
||||
|
||||
## Checklist Items
|
||||
|
||||
| # | Requirement/Question | Reference | C/NC/NA | Evidence/Notes |
|
||||
|---|---------------------|-----------|---------|----------------|
|
||||
| 1 | Are current versions of applicable procedures available? | SOP-001 | | |
|
||||
| 2 | Are personnel trained on applicable procedures? | SOP-003 | | |
|
||||
| 3 | Are training records current and complete? | SOP-003 | | |
|
||||
| 4 | Are records properly maintained and retrievable? | SOP-001 | | |
|
||||
| 5 | Are nonconformities being documented and addressed? | SOP-002 | | |
|
||||
| 6 | Are CAPAs being completed on time? | SOP-002 | | |
|
||||
| 7 | Is equipment calibrated and maintained? | | | |
|
||||
| 8 | Are process controls being followed? | | | |
|
||||
| 9 | Are quality objectives being monitored? | | | |
|
||||
| 10 | | | | |
|
||||
|
||||
**Legend:** C = Conforming, NC = Nonconforming, NA = Not Applicable
|
||||
|
||||
---
|
||||
|
||||
## Findings Summary
|
||||
|
||||
| Finding # | Type | Description | Clause Reference |
|
||||
|-----------|------|-------------|------------------|
|
||||
| | | | |
|
||||
| | | | |
|
||||
|
||||
---
|
||||
|
||||
## Auditor Signature
|
||||
|
||||
| Auditor | Signature | Date |
|
||||
|---------|-----------|------|
|
||||
| | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-006 Rev 1.0*
|
||||
265
Forms/Intake-Forms/FRM-OPT-001-New-Patient-Registration.md
Normal file
265
Forms/Intake-Forms/FRM-OPT-001-New-Patient-Registration.md
Normal file
@@ -0,0 +1,265 @@
|
||||
# New Patient Registration Form
|
||||
|
||||
| Form ID | FRM-OPT-001 | Revision | 1.0 |
|
||||
|---------|-------------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Patient Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Last Name | |
|
||||
| First Name | |
|
||||
| Middle Name/Initial | |
|
||||
| Preferred Name | |
|
||||
| Date of Birth | |
|
||||
| Age | |
|
||||
| Sex | ☐ Male ☐ Female ☐ Other |
|
||||
| Social Security # (last 4) | XXX-XX-_____ |
|
||||
|
||||
### Contact Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Street Address | |
|
||||
| Apartment/Unit | |
|
||||
| City | |
|
||||
| State | |
|
||||
| Zip Code | |
|
||||
| Home Phone | |
|
||||
| Cell Phone | |
|
||||
| Work Phone | |
|
||||
| Preferred Contact Method | ☐ Home ☐ Cell ☐ Work ☐ Email |
|
||||
| Email Address | |
|
||||
| OK to Leave Message? | ☐ Yes ☐ No |
|
||||
|
||||
### Additional Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Marital Status | ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered |
|
||||
| Race/Ethnicity (optional) | |
|
||||
| Preferred Language | |
|
||||
| Interpreter Needed? | ☐ Yes (Language: _______) ☐ No |
|
||||
| Employer | |
|
||||
| Occupation | |
|
||||
|
||||
---
|
||||
|
||||
## Emergency Contact
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Name | |
|
||||
| Relationship | |
|
||||
| Home Phone | |
|
||||
| Cell Phone | |
|
||||
| Work Phone | |
|
||||
|
||||
---
|
||||
|
||||
## Primary Care Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Primary Care Physician | |
|
||||
| Practice Name | |
|
||||
| Phone Number | |
|
||||
| Fax Number | |
|
||||
| Address | |
|
||||
| Date of Last Visit | |
|
||||
|
||||
---
|
||||
|
||||
## Referring Provider (if applicable)
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Referring Physician | |
|
||||
| Practice Name | |
|
||||
| Phone Number | |
|
||||
| Fax Number | |
|
||||
| Reason for Referral | |
|
||||
|
||||
---
|
||||
|
||||
## Insurance Information
|
||||
|
||||
### Primary Insurance
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Insurance Company | |
|
||||
| Policy/ID Number | |
|
||||
| Group Number | |
|
||||
| Policy Holder Name | |
|
||||
| Policy Holder DOB | |
|
||||
| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
|
||||
| Insurance Phone | |
|
||||
|
||||
### Secondary Insurance (if applicable)
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Insurance Company | |
|
||||
| Policy/ID Number | |
|
||||
| Group Number | |
|
||||
| Policy Holder Name | |
|
||||
| Policy Holder DOB | |
|
||||
| Relationship to Patient | ☐ Self ☐ Spouse ☐ Child ☐ Other: _______ |
|
||||
| Insurance Phone | |
|
||||
|
||||
---
|
||||
|
||||
## Responsible Party (if different from patient)
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Name | |
|
||||
| Relationship to Patient | |
|
||||
| Date of Birth | |
|
||||
| Address (if different) | |
|
||||
| Phone Number | |
|
||||
| Email | |
|
||||
|
||||
---
|
||||
|
||||
## Pharmacy Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Preferred Pharmacy Name | |
|
||||
| Address | |
|
||||
| Phone Number | |
|
||||
| Cross Street/Location | |
|
||||
| Preferred Mail Order Pharmacy | |
|
||||
|
||||
---
|
||||
|
||||
## Medical History Summary
|
||||
|
||||
### Current Medications
|
||||
*List all current medications including over-the-counter and supplements*
|
||||
|
||||
| Medication Name | Dose | Frequency |
|
||||
|-----------------|------|-----------|
|
||||
| | | |
|
||||
| | | |
|
||||
| | | |
|
||||
| | | |
|
||||
| | | |
|
||||
| | | |
|
||||
|
||||
### Allergies
|
||||
|
||||
☐ No Known Allergies (NKA)
|
||||
|
||||
| Allergen | Type | Reaction |
|
||||
|----------|------|----------|
|
||||
| | ☐ Drug ☐ Food ☐ Other | |
|
||||
| | ☐ Drug ☐ Food ☐ Other | |
|
||||
| | ☐ Drug ☐ Food ☐ Other | |
|
||||
|
||||
### Medical Conditions
|
||||
*Check all that apply*
|
||||
|
||||
| Condition | ☐ | Condition | ☐ |
|
||||
|-----------|---|-----------|---|
|
||||
| Arthritis | | Liver Disease | |
|
||||
| Asthma | | Lung Disease/COPD | |
|
||||
| Cancer | | Mental Health Condition | |
|
||||
| Diabetes | | Seizures/Epilepsy | |
|
||||
| Heart Disease | | Stroke/TIA | |
|
||||
| High Blood Pressure | | Thyroid Disease | |
|
||||
| High Cholesterol | | Other: _____________ | |
|
||||
| Kidney Disease | | Other: _____________ | |
|
||||
|
||||
### Surgical History
|
||||
|
||||
| Surgery/Procedure | Year |
|
||||
|-------------------|------|
|
||||
| | |
|
||||
| | |
|
||||
| | |
|
||||
|
||||
---
|
||||
|
||||
## Social History
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Tobacco Use | ☐ Never ☐ Current ☐ Former (Quit year: _____) |
|
||||
| If yes, type/amount | |
|
||||
| Alcohol Use | ☐ None ☐ Social ☐ Daily |
|
||||
| If yes, type/amount | |
|
||||
| Exercise | ☐ None ☐ Light ☐ Moderate ☐ Vigorous |
|
||||
| Frequency | times per week |
|
||||
|
||||
---
|
||||
|
||||
## How Did You Hear About Us?
|
||||
|
||||
☐ Physician Referral: _________________
|
||||
☐ Insurance Directory
|
||||
☐ Internet Search
|
||||
☐ Social Media
|
||||
☐ Friend/Family Member
|
||||
☐ Other: _________________
|
||||
|
||||
---
|
||||
|
||||
## Acknowledgments
|
||||
|
||||
### Financial Policy
|
||||
☐ I have read and understand the financial policy. I authorize payment directly to this practice of any insurance benefits otherwise payable to me. I understand that I am responsible for any amount not covered by insurance.
|
||||
|
||||
### Privacy Practices
|
||||
☐ I have received a copy of the Notice of Privacy Practices and understand how my health information may be used and disclosed.
|
||||
|
||||
### Release of Information
|
||||
☐ I authorize the release of medical information necessary to process insurance claims and for continuity of care with referring and consulting physicians.
|
||||
|
||||
### Communication Authorization
|
||||
☐ I authorize communication via: ☐ Phone ☐ Email ☐ Text Message for appointment reminders and health information.
|
||||
|
||||
### Assignment of Benefits
|
||||
☐ I authorize payment of medical benefits to this practice for services rendered.
|
||||
|
||||
---
|
||||
|
||||
## Patient Portal
|
||||
|
||||
☐ I would like to enroll in the patient portal
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Preferred Email for Portal | |
|
||||
|
||||
---
|
||||
|
||||
## Signature
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Patient/Guardian Signature | |
|
||||
| Printed Name | |
|
||||
| Relationship (if not patient) | |
|
||||
| Date | |
|
||||
|
||||
---
|
||||
|
||||
## For Office Use Only
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Date Received | |
|
||||
| Entered By | |
|
||||
| Chart Number | |
|
||||
| Insurance Verified | ☐ Yes |
|
||||
| Copay Collected | $ |
|
||||
| Notes | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-OPT-001 Rev 1.0 - New Patient Registration Form*
|
||||
0
Forms/Patient-Intake/.gitkeep
Normal file
0
Forms/Patient-Intake/.gitkeep
Normal file
0
Forms/Procedure-Records/.gitkeep
Normal file
0
Forms/Procedure-Records/.gitkeep
Normal file
0
Forms/QI-Records/.gitkeep
Normal file
0
Forms/QI-Records/.gitkeep
Normal file
0
Forms/Referral-Forms/.gitkeep
Normal file
0
Forms/Referral-Forms/.gitkeep
Normal file
72
Forms/Training/FRM-004-Training-Record.md
Normal file
72
Forms/Training/FRM-004-Training-Record.md
Normal file
@@ -0,0 +1,72 @@
|
||||
# Training Record Form
|
||||
|
||||
| Form ID | FRM-004 | Revision | 1.0 |
|
||||
|---------|---------|----------|-----|
|
||||
|
||||
---
|
||||
|
||||
## Section 1: Employee Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Employee Name | |
|
||||
| Employee ID | |
|
||||
| Department | |
|
||||
| Job Title | |
|
||||
|
||||
## Section 2: Training Information
|
||||
|
||||
| Field | Entry |
|
||||
|-------|-------|
|
||||
| Training Title | |
|
||||
| Training Date | |
|
||||
| Training Duration | |
|
||||
| Trainer Name | |
|
||||
| Trainer Qualification | |
|
||||
|
||||
### Training Type
|
||||
- [ ] Initial Training
|
||||
- [ ] Retraining
|
||||
- [ ] Refresher
|
||||
- [ ] Procedure Update
|
||||
|
||||
### Delivery Method
|
||||
- [ ] Classroom
|
||||
- [ ] On-the-Job
|
||||
- [ ] Self-Study
|
||||
- [ ] Computer-Based
|
||||
- [ ] Other: ____________
|
||||
|
||||
## Section 3: Training Content
|
||||
|
||||
*(List topics covered or attach training materials)*
|
||||
|
||||
|
||||
|
||||
|
||||
## Section 4: Assessment
|
||||
|
||||
### Assessment Method
|
||||
- [ ] Written Test
|
||||
- [ ] Practical Demonstration
|
||||
- [ ] Verbal Assessment
|
||||
- [ ] Observation
|
||||
|
||||
### Assessment Results
|
||||
|
||||
| Metric | Result |
|
||||
|--------|--------|
|
||||
| Score (if applicable) | |
|
||||
| Pass/Fail | |
|
||||
|
||||
## Section 5: Signatures
|
||||
|
||||
| Role | Name | Signature | Date |
|
||||
|------|------|-----------|------|
|
||||
| Trainee | | | |
|
||||
| Trainer | | | |
|
||||
| Supervisor | | | |
|
||||
|
||||
---
|
||||
|
||||
*Form FRM-004 Rev 1.0*
|
||||
0
Forms/Visit-Documentation/.gitkeep
Normal file
0
Forms/Visit-Documentation/.gitkeep
Normal file
Reference in New Lab Ticket
Block a user