Medical
Physician Change Order Form
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Physician Change Order Form

1
Physician initiates request for change order
2
Identify and document the reason for change
3
Create a draft of change order request form
4
Review current treatments or procedures affected
5
Determine how change affects planned treatments or procedures
6
Approval: Medical Director
7
Submit form to physician committee
8
Committee reviews and discusses the change
9
Approval: Committee Review
10
Revise change order request form based on feedback
11
Resubmit to committee if revisions are significant
12
Approval: Revision Resubmission
13
Confirm physician acknowledges and accepts change order
14
Forward the change order to administration department
15
Update medical and administrative records
16
Notify relevant staff about the change
17
Implement the approved change order
18
Monitor and evaluate the impact of the change order
19
Document the outcomes and lessons learned
20
Close the change order process