VA Form 10-10M, Medical Certificate

VA Form 10-10M, Medical Certificate, is a Veterans Health Administration (VHA) form of the U.S. Department of Veterans Affairs that documents a patient's medical encounter: condition on arrival, vital signs, history and physical, diagnostic impressions, plan and the discharge instructions given to the patient.

The form has two parts. Section I, on the front, is completed by the treating staff. Items 1 to 7 capture the date, time, age, sex, how the patient arrived (ambulatory, stretcher or wheelchair), phone number and whether the patient is homeless. Items 8A to 8G record allergies, weight, temperature, pulse, respiration, blood pressure and whether the condition is due to injury. Items 9 to 14 cover current medications, triage, signature, history and physical, diagnostic impressions and plan. Item 15 identifies the attending of record and carries the examiner's signature.

A continuation page provides a vital signs table, physician and nurse orders with effectiveness, and studies requested with results. It is headed "Continuation from front/progress note".

Section II, "For patient," records the disposition or clinic appointment, whether an after care sheet was given, follow-up, activity and limitations, the patient's condition (improved, satisfactory or unchanged), the date and time of discharge and the patient instructions. The patient signs to certify receiving and understanding them. A patient's copy of Section II is included as the last page.

The December 2016 revision supersedes the May 1990 edition of VA Form 10-10M, which the form says will not be used.

VA Form 10-10M is a clinical record, so it is completed by the VHA staff who treat the patient and, in Section II, by the patient. The form itself names the roles involved: the examiner and the attending of record sign Section I, a physician (MD) and a nurse sign the orders on the continuation page, and a staff member signs Section II, item 6 to show that instructions were given.

The patient signs Section II, item 8, under the printed statement "I certify that I received and understand these instructions." The form has an area to imprint the patient data card.

The form prints no eligibility rules, no list of people who must use it and no instruction on who may sign for a patient who cannot sign. For questions about whether a particular visit calls for this form, ask the VA facility that is treating the patient.

VA Form 10-10M is completed during the patient's visit rather than filed by a deadline; no due date is printed on it. Section I starts with the date and time of the visit (items 1 and 2), and Section II closes with the date and time of discharge (item 5) and the signatures that show the instructions were given and received. The form tells staff to continue on the back when necessary, and the continuation page is used for orders, studies requested and results as the visit goes on.

VA Form 10-10M prints no mailing address, portal or submission instructions. The form is a VHA clinical document: the VA lists it as a VHA form at https://www.va.gov/forms/10-10m, and the completed form stays with the facility that treated the patient. Section II is meant for the patient, and the last page of the PDF is marked as the patient's copy.

Because the form names no channel, follow the instructions of the VA facility where it is used. FillingPDF lets you fill out and download the PDF; submission follows the channels of the agency or facility that asks for the form.