Designing medical record forms

Medical records specialists are often consulted when new forms for recording data were needed or revision of old ones became necessary. Their expertness is useful for assuring that the terminology used and the information derived will be compactable with the whole system. Keeping abreast of new development in data system and of progress in the standardization of terms, will be invaluable to the medical records director who is asked to assist in new projects of quality control.

 Who design form?

Forms may be designed centrally, it depends on institution. Under normal circumstance the health records sub-committee has prerogative power to design forms. Thoughtful design of form makes it more readable, useful and less bulky.

The constituent of health record sub-committee

Health records officer is an active member of the committee. He/she advices the committee with the expert knowledge and as such he/she is the secretary. Other members include physicians of the hospitals as the chairman, head of nursing, pharmacist, administrator are members. In case of teaching hospital, some clinical heads of whose discipline are relevant has to be a member as the case warranted.

Duties of health records sub-committee

The reviews of new forms are proposed by medical staff of various departments. Revision of the form in use and the discontinuing of the forms that are no longer needed.

Duties of health records officers in designing of forms

In some aspect, the duties of health records officers are closely related to that of the printer. Health records officer reads the printed sample form. The printer makes amendments where necessary before returning back to printer for final printing.

The replicate proof of health records officer forms the authentic print out of the printer.

The following are the technical duties of health records officers:

  1. He makes available the requirement for printing forms.
  2. He spells out or he confirms the statute that is the policy that may control the content of the form in the state or institution.
  3. He also advices with professionals, technocrats on quality, quantity, spacing, printing style, logical sequence of the material, etc.
  4. He collects sample, proof read the sample and correct the sample.
  5. He is involved in taking the stock, attending to requisition and distribution of forms. That is, he serves as the link between the users and the committee.
  6. He is involved in the training of the user.

Printer’s obligations in printing of forms

Apart from the institution policy on stock/supply bureaucracy, the printer and the health records officer should be in close contact. The printer advices on the following:

  1. Quality of the form.
  2. Size of the type/margin, paper colour, text colour, texture, thickness, weight.
  3. He reprints after the final proof reading.

Form management control

The medical records specialist should also in cooperation with medical records committee set up a control of the forms used in the medical records itself. This will eliminate unnecessary duplication of information, attain uniformity of content, appearance, and size. Form management control includes:

  1. The need for designing form
  2. Availability of form
  3. Health records officer must accept requisition of forms.
  4. Regulate the distribution of forms.
  5. Modify forms when necessary.
  6. Revising the form and the use
  7. Putting the user through on the use.
  8. Monitoring the rate of consumption
  9. Taking regular stock and prepare for printing before exhausting the available ones.
  10. Maintaining extra copy of each kind of form.
  11. Must be able to locate and identify each form
  12. The custodian of the forms.

A form inventory by number and use should be available and should be periodically surveyed for possible revisions, additions or deletion in the individual form to meet current need. Advancement in methods as well as in medical knowledge will make such changes necessary.

Multiple form

Patient data may be needed in more than one or two places. In this case multiple form is recommended. If there is the need to retain a copy of the form when the original is needed or a form is needed in about two or more places e.g.

It is a good advantage to employ this system if for the following reasons. Multipart forms avoid duplication which may bring about the following:

  1. Error in duplicates is impossible
  2. It reduces cost
  3. It saves time
  4. It reduces labour
  5. It gives room for extra copy e.g. of multipart form

 

  1. Carbon copies e.g. a type writer with carbon
  2. Loose carbon is inserted between forms
  3. snap-out e.g. x-ray report
  4. Forms with carbonised back.
  5. Stencils
  6. Photocopies
  7. Electronic translation of data

Colour coding

This is highly recommended in a situation where a particular form is to be used in different unit for related services. Instead of duplicating the form, the right hand margin can be marked with colour code bind. This will distinguish form among one unit and the other.

Disadvantages

  1. There will be confusion in selecting other colour of the colour in use is out of stock.
  2. Colour coding is expensive.
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