Medical Record Release Form and Medication Safety Protocols

  • CAP has revised its Medical Record Release Form font size (Authorization for Use and Disclosure of Medical Information) per regulation of the California Medical Information Act. 
  • Recommendations for establishing written protocols for ordering and/or administration of medications in the office.

CAP's Revised Medical Record Release Form and the Importance of Font Size and Style

CAP has revised its Medical Record Release Form (Authorization for Use and Disclosure of Medical Information) font size per regulation of the California Medical Information Act requiring a typeface no smaller than 14-point type. CAP’s template has increased from one to two pages, with no other changes. Click here for a new Authorization for Use and Disclosure of Medical Information template.

Ever wonder how your documents “appear” to patients when they are asked to complete them to obtain accurate information? General guidelines for ease are:

  • Type in size 10 to 14, with 12 and 14 commonly selected. Though specific format guidelines exist for certain forms and publications, create office forms with font sizes easily readable for persons of all ages and experiencing various health conditions, and written in a language that should not be higher than a sixth to eighth grade level.  
  • Font styles with “serifs,” the little “feet” at the ends of letters, look more traditional and are usually easier to read in large blocks of text as they makes the individual letters more distinctive and easier for our brains to recognize quickly. Examples are Century and Times New Roman.  
  • Sans serif fonts, “sans” meaning “without” any extra stroke at the ends of letters, are more “modern” and simple when type must be small. Headings, subheads and websites are frequently typed in sans serif. Examples are Arial and Tahoma.

When printing using these suggested font sizes and styles, both gathering and providing information may facilitate better patient understanding.

Submitted by Jackie Gellis, MHA, RN
Senior Risk Management & Patient Safety Specialist


Ways to Improve Medication Safety in the Physician's Office

In office settings, situations in which medication errors might occur include injections in the office, samples dispensed by physicians, and prescriptions filled by pharmacies. Following are a few general recommendations to help avoid these errors. 

Establish written protocols for ordering and/or administration of medications in the office. The protocols should include:

  • Readable medication written orders. If staff is unable to read a handwritten order, the order should be double checked with the physician or practitioner (NP/PA) who wrote it.   
  • If the medication is being E-prescribed, the ordering physician or NP/PA should do the E-prescribing.
  • The person(s) responsible for administering oral or injectable medications.
  • Specific medication(s) that may be administered by individuals based on their level of education and training.  
  • A system of double checking orders with another clinical staff member to assure the 5 R’s (right drug, right dosage, right site, right time, right person) before administration in the office .
  • A requirement that immediate documentation be made in the patient’s medical record after administration. This should include at a minimum 1) the name of the drug, 2) the site administered, 3) the lot number and 4) the expiration date.
  • Procedures to handle questions posed by a patient, parent, or other caregiver. Office personnel should listen and answer questions, as appropriate and, if necessary, double check with the physician or NP/PA.

Submitted by Sue Jones, BA, LVN, CPHRM
Senior Risk Management & Patient Safety Specialist

 

If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.