Templates: Consent Forms

Consent forms can be provided to patients, guardians, and guarantors for review and signature. These forms are generally used to provide important information and receive consent for treatment, documents release, financial agreements, and many other forms. 

Creating Consent Forms

Each Kipu EMR Instance contains a set of default consent forms in addition to any forms created specifically for your organization during implementation. Let's review how to create a new consent form. 

From the Templates tab, open the Consent forms tab and click New Form.

Consent Form Settings

From the new Consent Form, you have a collection of settings that control the forms available and behavior.

Check out the following field definitions. The first two fields are the form name (required) and the Patient Process drop-down which indicates where on the patient's chart this form should live.

• Note: If you can't find a form, check this drop-down which will show you exactly where to go to add it to the patient chart. 

1. Enabled: Check this box to make the form available for use within your instance. 
2. Load manually: Check this box to prevent the form from being added when the Populate with Forms button is selected on the patient chart. The form can only be added using the Add form button on the patient chart tab. 
3. One per patient: Check this box to if this consent form can only be added to the patient's chart once (one-time-only form).
4. Allow attachments: Check this box to indicate that attachments can be added to the form.
5. Allow revocation: Check this box if the form can be revoked by the Patient, Guardian, or Guarantor. This is typically used in Release of Confidential Information (ROI) forms. 
6. Form expires: This field allows you to indicate whether or not the form will expire. 
7. Expires in days: Once you have checked off the Form expires box, use this field to indicate how many days should pass before the form expires. 

1. Consent form type: Select Standard form (requires the patient to have an MR Number to add the form to the patient chart) or Pre-admission form (does not require the patient to have an MR Number to add the form)

2. Rules: The rules drop-down allows you to choose how the form should behave. You can select one rule per consent form. The following options are available for selection:

   

   • Create for all patient contacts: This will automatically generate a copy of this form for each of the contacts included on the patient facesheet at the time the form was added. This is typically used for Release of Information (ROI) forms.
   • Create for referrer/discharge to: This will automatically generate a copy of this form for the referrer and discharge facility that are present on the patient facesheet at the time the form was added, typically used for Release of Information (ROI) forms.
   • Only if patient has insurance: This will generate a copy of this form for all patients with insurance information.
   • Only if patient is female: This will generate the form for female patients only (this is helpful for things like a pregnancy test consent form).
   • Only if patient is male: This will generate the form for male patients only.
   • Only if patient is transgender: This will generate the form for patients whose gender identity differs from their birth gender. Click here to learn about the Gender Identity functionality.
3. SMS consent: Appears when the Call Backs feature is enabled to indicate that the patient must sign this form before they can be contacted via SMS message.
4. Required for lab requisitions: This field is only available for facilities using the Lab Interface and must be configured by a Kipu Employee. Please do not check this box, as this will make the form uneditable. 
5. Requiring lab: This field is only available for facilities using the Lab Interface and must be configured by a Kipu Employee. Please do not check this box, as this will make the form uneditable. 

1. Portal: If you want this form to be available on the portal, check off this box.
   1. If you select the Available checkbox, the Signatures Only option will appear. If this box is checked off, patients will only be able to open and sign the form in the Patient Portal, they will not be able to make any other changes.
2. Required Signatures: Use these check boxes to indicate which signatures are required.
   • Patient: Require the Patient signatures on this form to mark it as "Signed."
   • Guardian: Require the patient's Guardian to sign this form. Click here to learn more about Guardian functionality.
   • Guarantor: This checkbox is typically used for financial documentation. Click here to learn about Guarantor functionality.
   • Staff: Require a staff member to sign this form. Any staff user can sign the form regardless of their assigned function.
3. Locations: Use the checkboxes to select the Locations where the consent form will be used (master instances only).
4. Link consent form: Allows previously created forms to be linked together, making the linked form into a draft. You can unlink them just as you would a normal draft.

Signature Behaviors

For a form that has signature requirements for the Patient, Guardian, and/or Guarantor but does not have a Staff signature requirement:

•  If the form is signed by the Patient before a Guardian/Guarantor is added as a Contact on the facesheet, the form will have fulfilled its requirement of getting the Patient's Signature and will display as Completed.
• The form will not recognize a Guardian or Guarantor being added as a contact after the form has met the Patient signature requirement since, at the time of signing, only a Patient signature was needed and thus the form was set to the completed status. If you need to collect the Guardian/Guarantor signatures, a new form will need to be added and resigned to capture all the intended signatures.

For a form that has the signature requirements of the Patient, Guardian, and/or Guarantor, and Staff signatures:

• The patient can sign the form and as long as the staff signature hasn't been added, the form will not move to a completed status. 
• When the Guardian/Guarantor is added as a contact on the patient's chart after the patient has signed but before the staff member has signed, the guardian/guarantor will be populated as a signer on the form because the form is not in a completed status. 
• Once added as contacts and the form recognizes the need for a Guardian/Guarantor signature, it will then allow them and the Staff to sign.

Consent Form Fields

Once you've configured your consent settings, let's review how to build your consent form template in the Form section. The form builder looks very similar to word processing software and functions similarly as well. 

You can enter the text of your form directly into the form, and include:

• Data fields: These fields are dynamic variables that allow you to create a generic form and automatically populate information related to the patient like patient name, program, and insurance plan. 
• Form fields: These fields allow you to create interactive elements to enhance the form by adding checkboxes, radio buttons, text boxes, date selection widgets, and more.

Data Fields

All available Data Fields are listed below the main form editor and are described here with examples:

Data Field Shortcode	Description	Example
[data_field.patient.bed]	If occupancy is used, this is the patient bed assignment	CG R2:B1
[data_field.patient.name]	The patient's first and last name	Anna Greg
[data_field.patient.mr]	The patient's MR/Chart Number	CGP2022-61
[data_field.patient.id]	The patient ID (primarily used by MAT clinics)	785460
[data_field.patient.dob]	Displays the patient's DOB	01/10/1977
[data_field.patient.gender]	Displays the patient's gender (female/male)	female
[data_field.patient.age]	Shows the patient's age (as calculated by DOB)	45
[data_field.patient.ssn]	The patient’s social security number	999-99-9999
[data_field.patient.admission_date]	The patient’s admission date	08/09/2022
[data_field.patient.address]	The patient’s full postal address	12345 Main Street Los Angeles, CA 98005
[data_field.patient.email]	The patient’s email address	[e-mail]
[data_field.patient.phone]	The patient’s phone number	871-231-6817
[data_field.patient.program]	The patient’s currently assigned program	IOP
[data_field.patient.gender_identity	The patient's gender identity	Non Binary
[data_field.patient.diagnosis]	The patient's diagnosis code(s)	F11.188 Opioid-induced anxiety disorder, With mild use disorder
[data_field.insurance_names]	The patient’s insurance company name	Aetna
[data_field.insurance_ names_policy_phone]	The patient’s insurance name and policy number	Aetna Policy 23867623
[data_field.insurance_benefits]	The patient’s insurance benefits information
[data_field.company_name]	The Company name	Kipu Treatment Centers
[data_field.company_address]	The company's address	55 Alhambra Plaza, Miami, FL, 33314
[data_field.company_phone]	The company's phone number	561-349-5911
[data_field.company_fax]	The company's fax number	561-574-5681
[data_field.company_county]	The company's county	Dade
If your facility has more than one location, the following data fields will pull from the specific location the patient is assigned to. If the patient isn't assigned to a Location, these fields will display the corresponding company fields.
[data_field.location_name]	The location name	Coral Gables Programs
[data_field.location_address]	The location address	11000 SW 57th Ave, Pinecrest, FL 33156
[data_field.location_phone]	The location phone number	305-683-6250
[data_field.location_fax]	The location fax number	305-477-7490
[data_field.location_county]	The location county	Dade
[data_field.rule_block]	Shows information related to the selected Rule, e.g., if the rule selected is "create for all patient contacts", you'll see a list of the patient's contact and their information	John Gregory Relationship: Guarantor   Phone: [phone]

Data Fields in Action

To use these fields within the form builder, simply copy and paste in the desired dynamic variable where you would like the specific data to appear.

When this form is added to a patient chart, the variables will display the information related to that patient.

Form Fields

These fields allow you to create interactive elements to enhance the form by adding checkboxes, radio buttons, text boxes, date selection widgets, and more. Form fields require a unique name in order to save correctly within the form e.g., [form_field.uniquename list]. This name can be whatever you would like as long as each field is named uniquely. Note: Any field highlighted in red below should be updated when using the shortcode in the consent builder.

Form Type	Example
List Allows you to add a drop-down menu that allows the patient to select one option.  [form_field.uniquename list options("option1","option 2")]	Select the card type: [form_field.creditcard list options("Visa","MasterCard","American Express","Discover")]
Text Adds a small text box. You can add a secondary parameter to your text field to specify the width of the text box. Set the desired width as a percentage of overall page size e.g. 10% of the screen size would be width="10". [form_field.uniquename text] or [form_field.uniquename text width=“10”]	Standard text box: [form_field.box1 text] This is what a width of 10 looks like: [form_field.box2 text width="10"]
Text Area Adds a large text box. [form_field.uniquename text area]	Example: [form_field.large textarea]
Date Selector Select a date from a pop-up calendar. [form_field.uniquename date]	Select the date of last use: [form_field.lastuse date]
Checkbox Off Adds a checkbox that is unselected by default. [form_field.uniquename checkbox_off]	[form_field.off checkbox_off]  [form_field.on checkbox_on]
Checkbox On Adds a checkbox that is checked by default. [form_field.uniquename checkbox_on]
Radio Buttons Adds Yes or No radio buttons (single selection). [form_field.uniquename radio_yes_no]	Are you ready for treatment? [form_field.rb radio_yes_no]
Radio Buttons w/  "Yes" warning Adds yes or no radio buttons. If the patient selects Yes, a warning message pops up for their acknowledgment. [form_field.uniquename radio_yes_no "warning text"]	Are you considering self-harm? [form_field.harmwarning radio_yes_no "If you answer yes, you'll be placed under watch for 72 hours"]
Form Title This field adds whatever item/data is included will be added to the title of the consent form within the patient chart tab. This field can only be used once per consent form. You can use any of the field types and replace text with list options("option1","option 2")] or Radio buttons, etc. [form_field.form_title text] [form_field.form_title list]	Do you understand what you've read? [form_field.form_title text] Form field Chart tab

Visual Customization

You can further customize your form by adding your logo, a picture, and inserting tables. All formatting options are available at the top of the form builder.

Type in your form's content. If you choose to copy and paste text from an existing external document, we recommend copying the document as plain text. Once the contents are pasted in, ensure the entire form is highlighted (try Ctrl + A or Cmd + A), then click the Clear Formatting button.

You can add any Data Field or Form Field (described above), by inserting them in your desired place within the form.

Add Images

Any images (logos/pictures) added to the form must be added by URL. This ensures the image is stable and doesn't impact form performance. You can convert your JPEG or PNG files to image URLs for free on numerous websites, simply search online for "How To Convert Image Files To Image URL".

Important: Images will always default to the original size of the image you uploaded. 

1. Click on the Image icon in the toolbar.
2. Add the image URL in the Source field.
   
3. We recommend ensuring the Constrain proportions checkbox remains checked. This helps ensure the image is added in the correct dimensions and isn't skewed. 
4. Click Ok to add.
   
5. Remember, the image size cannot be adjusted and will default to the size of the original image. 

Add Tables

Tables can be very helpful for organizing information into evenly spaced columns or grids.

1. To build a table, click on the Table icon.
2. Hover over the Table menu and use the grid to select the number of columns and rows you need for the table.
   
3. Next, enter the data into the table. By default, the columns are collapsed so they can be a bit hard to see. Once you add data, they will automatically expand.
4. Once you have your table data entered, let's review some formatting tips.
5. Format the text using any of the text options available within the Editor. Adjust the size, make the font bold, change the font color, etc. You can also add links as needed.  
6. Add additional blank columns between the existing columns and put a few spaces (using your space bar) into the column to provide some padding between information columns. This ensures your text doesn't appear squished. 
7. To merge cells, highlight the cells you want to merge and right-click with your mouse. Hover over Cells and choose Merge cells.
8. Use Table Properties to fine-tune your table appearance and add borders, colors, and manage the alignment of text within the cells.
9. If you'd like to make changes to the appearance of some individual cells, highlight the cells and right-click. Hover over Cells and choose Cell properties. You can use this feature to make header cells.
   
10. If you'd like to make changes to the appearance of full rows, highlight the row and right-click. Hover over Row and choose Row properties.

Previewing the Form

Once you've completed adding your form information, we recommend previewing the form on a test patient. This allows you to view how the form will look when added to the patient tab. The formatting will be different than what appears in the form editor.

1. Click Create or Update to save.
2. Open a test patient chart and navigate to the tab where the form has been assigned (view this information under Patient Process).
3. From the tab, click Add form.
   
4. Select the form from the pop-up.
   
5. Click on the form name to view.
   
6. Review the form and determine if any updates are needed. Typical updates include adding additional space between sections or paragraphs, adding additional verbiage, or updating the text appearance (size, color, or bold/italics). 
7. If you make updates to the form in the Templates section, be sure to delete the form added to the patient chart and re-add it. This allows you to view the latest version of the form.

Pre-Admission Consent Forms

Create consent forms designed to be completed in the pre-admission stage, collecting Patient, Guardian, and/or Guarantor signatures before the admission date. These consents do not require the patient to have an MR Number to be added to the patient's chart. 

When creating or editing a consent form, select Pre-Admission from the Consent form type drop-down.

Pre-admission form creation is exactly the same as standard consent forms. However, some data fields (e.g., [data_field.patient.ssn] or [data_field.patient.admission_date]) may not populate with any information if that data hasn't been added to the patient chart yet. Which data fields you choose to use depends on the information your facility requires to be collected on a pre-admission chart. 

Click Update to save.