10-10M
Medical Certificate
VA Form 10-10M is the U.S. Department of Veterans Affairs Medical Certificate, listed under VHA on VA's page. It is a clinical record of a patient's visit: the date and time, how the patient arrived, allergies and vital signs, current medications, triage, history and physical, diagnostic impressions and the plan, with the attending of record and the examiner's signature.
Section II, For Patient, covers the disposition or clinic appointment, whether an after care sheet was given, follow up activity limitations, the patient's condition, the date and time of discharge and the patient instructions. The patient signs to certify receiving and understanding these instructions. The form prints no filing instructions or mailing address.
The PDF has three pages: the certificate, a back page for vital signs, orders, a progress note and studies requested, and a patient's copy of Section II. You can fill out the PDF free in your browser on this page and download the result without an account.
Date, time, age and sex, whether the patient arrived ambulatory, on a stretcher or in a wheelchair, phone number, homeless yes or no, allergies, weight, temperature, pulse, respiration, blood pressure and whether the visit is due to injury.
Current medications, a triage space and a signature line.
History and physical, diagnostic impressions, the plan, the attending of record and the examiner's signature.
Disposition or clinic appointment, after care sheet given yes or no, follow up activity limitations, condition (improved, satisfactory or unchanged), discharge date and time, a signature to indicate instructions given, patient instructions, a box to imprint the patient data card and the patient's signature.
A vital signs log by time, orders with MD and nurse signatures, a continuation from the front or progress note, and studies requested with results.
A second copy of Section II, For Patient, marked Patients Copy.
Fill in Items 1 to 8G with the date and time, how the patient arrived, allergies and vital signs.
Enter current medications, triage notes, the history and physical, diagnostic impressions and the plan in Items 9 to 14.
Name the attending of record in Item 15A and sign Item 15B, the examiner's signature.
The top of the form says to continue on back when necessary. Page 2 holds the continuation from the front or progress note.
Fill in the disposition, condition, discharge time and patient instructions, sign Item 6 to indicate instructions given, and have the patient sign Item 8.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form prints no mailing address or filing instructions.
Page 3 repeats Section II, For Patient, and is marked Patients Copy.
Pages 1 and 2 print DEC 2016, matching the December 2016 revision date on VA's form page. Page 1 says it supersedes VA Form 10-10M, MAY 1990, which will not be used. The page 3 footer prints MAR 1992.
The form has places for these people to write or sign.
No tool matches that search.
It is the VA Medical Certificate, listed under VHA on VA's page. It records a patient's arrival, vital signs, triage, history and physical, diagnostic impressions, plan and discharge instructions.
The form has a signature under triage, the examiner's signature in Item 15B, MD and nurse signature columns on page 2, a signature to indicate instructions given in Section II, and the patient's signature in Item 8.
Disposition or clinic appointment, whether an after care sheet was given, follow up activity limitations, the patient's condition, discharge date and time, and patient instructions.
Page 3 of the PDF repeats Section II, For Patient, and is marked Patients Copy.
No. The form prints no mailing address or filing instructions.
The PDF prints DEC 2016, matching VA's page. It says it supersedes VA Form 10-10M, MAY 1990, which will not be used.
