Aravind Eye Care System.
A Medical Record Form is a piece of paper or card on which a formal arrangement of information is designated usually with spaces for the entry of additional data. Each hospital has the responsibility to develop medical record forms to fit its needs. Thoughtful designs of the forms, which will become part of the medical record, will provide a more readable, useful, and less bulky record. Medical record forms are essential ingredients for smooth and efficient functioning of the hospital.
Purpose of Medical Records Forms:
Medical record forms can accomplish several purposes:
Principles of forms design
- To communicate patient health care and to facilitate medical education, medical research and legal requirements.
- They can reduce writing time.
- Well-designed forms are also easier to fill out.
- It will provide uniformity in paper work.
As it is estimated that 0.5% of total hospital expenditure is spent on medical records forms, before a new form is developed or an existing form revised, the following steps can be used to compile the necessary facts and to determine what, if any, improvements should be made.
In the development of a new form, it is advisable to ponder on the following
- Is the form really necessary?
- What benefits will be derived from introduction of the form into the record?
- The purposes of the form will in turn determine the information to be included on it. Unnecessary information must not be included.
- To have only a small supply of forms prepared for trial use, because experience frequently indicates a need for revisions. Since cost is also a factor in continually revising and printing small quantities of forms,
- Photocopying might be the reproduction method of choice.
- Forms should be kept simple and the variety few in number to provide flexibility and reduce record bulk.
- All discontinued forms should be removed from the stockroom or supply area and destroyed.
The printer can ordinarily give advice on the physical aspects of printed forms the kind and size of types, margins, paper color and weight, ink, and size of the form. Remember that standard size forms are always less expensive, facilitate filing, preclude loss, which is often the case with irregular paper sizes. Different colors of paper and ink will affect photocopying and microfilming in different ways.
- A uniform size of paper should be used. Although standard size (8 -inch by 11-inch) paper is most commonly used, 8- -inch-by-5 -inch papers could be used to reduce waste.
- A uniform binding edge should be maintained, either a top or side binding.
- A uniform margin that is based on the binding edge should be maintained. Chart folders on the nursing units should accommodate the uniform margins.
- For top binding, information on forms that are to be printed on both sides should be correctly placed on both sides for proper assembly in the chart. For side binding the two sides should be placed head-to-head.
- Line spaces should be assigned on the basis of whether the forms are to be typewritten, handwritten, or both.
- The quality and weight of paper should be selected according to the expected life of the record, the amount of use it will receive, and whether both sides are to be used. If both sides will be printed, the paper must be heavy enough to prevent the ink from showing through.
- Colored forms should be selected carefully because problems can occur in photocopying or microfilming colored sheets. White paper with color-coded borders will prove more effective for quick identification of different forms in the hard-copy record.
- When feasible, using a rubber stamp on an existing form can eliminate the need for special forms that are not used regularly.
Basic Medical Records Forms
A total of 15 basic forms have been recommended in this manual. The person using these forms must adhere to the format and contents prescribed and try to complete them as comprehensively as possible. Generally these forms are self explanatory but however, the following instructions should be observed for effective maintenance of medical records.
Admission and discharge sheet
The treating physician should document a provisional diagnosis at the time of admission and at the time of discharge should document final diagnoses, principle and associated secondary diseases. If an operation was performed, the face sheet must contain the name of the operation, the anesthesia given, the date and time of discharge and the condition of the patient on discharge.
History and Physical Examination Form
A complete history should be written describing the chief complaint, the details of the present illness, and the patients past medical history, social history, and family history. The physical examination form should include all pertinent findings resulting from an assessment of all the systems of the body. It should be recorded within 24 hours of the admission of the patient.
Progress Notes Form
Progress notes should be written as frequently as required by the condition of the patient. Progress notes should provide a reference to the condition of the patient on admission. A chronological record of the patients progress should be documented daily or even every few hours during a critical illness. Progress notes should conclude with a summary of the patients general condition.
Physicians orders must be complete, specific, legible, and exact. All orders must be written in ink, signed, and dated. Oral orders and orders over telephone to house staff or nurses should be entered in the record and countersigned by the physician within 24 hours.
A written requisition filled in on the consultation form and indicating full details of the provisional diagnosis, the objective of the consultation and all relevant clinical points on which an opinion is desired constitutes the consultation form. The consultant after conducting his own examination then records his findings and recommendations on the same form and signs it.
Consent to Operations and Investigations
A general consent for diagnostic investigation and treatment must be obtained at the time of admission as a routine procedure. Special consent must be obtained for: surgical procedures, discharge against medical advice, temporary leave of absence, photographic imaging, release from responsibility for abortion, sterilization, organ donation, organ transplantation, or autopsy.
A complete anesthesia record indicates the preoperative medications given, the date, time, and effect of these medications, the type and amount of anesthetic administered, and the technique used.
Operation Report Form
The operation report form should include a preoperative diagnosis, the name of operation and a full description of the findings, both normal and abnormal of all organs explored and the procedures, ligatures, and sutures used in the operation, the tissues removed or altered, the postoperative diagnosis, the patients condition at the conclusion of the procedure. The material (tissue) removed and sent for histopathological examination must be entered in the operation record. The operation report should be written or dictated immediately after the operation if possible, or at least within 24 hours.
Investigation request and report forms
All requests for diagnostic investigations of blood, urine, stool, etc must be recorded. It should contain complete and correct patient identification data. The physician requesting the investigation should indicate the name of the unit or clinic, the provisional diagnosis, and type of test requested in the prescribed manner. This form should contain the date and time requested and name of the physician requesting the test.
Blood Transfusion Request form
The blood transfusion request form is retained as part of the patient file. This record should contain the type of blood needed, the amount of blood requested for the patient, the date and time the blood transfusion was given, and any reaction noted.
This form includes cuttings from standard leads traced and the cardiologists
impression. The original tracings are mounted on the folder in the appropriate place.
Nurses Notes Form
Nurses notes encompass the observations, treatments, and services rendered by them to the patient. The nurses notes must give a chronological picture of nursing care. Precise nursing notes act as a means of communication among nursing personnel and physicians. These notes should also include the date, time, and manner of patients admission wheelchair, stretcher, ambulance, etc. Interim notes during hospitalization, and a note written at the time of patients discharge including the date and time of discharge, any advice given to the patient, the manner of patients discharge wheel chair, stretcher, ambulance, etc must be recorded. If the patient dies, nursing notes must include the date and time when life apparently ceased, and the name of the physician pronouncing the patient dead. All notes must be signed and dated with the time also indicated.
The temperature, pulse, and respirations chart allows for a four hourly or twelve hourly entry of temperature, pulse and respirations. There is also space for the graphic recording of blood pressure, as well as written comments on urine, stool, weight, diet, and any other observations required. This chart should be initiated in the ward on the admission of the patient and be continued until the time the patient is discharged.
Fluid Balance chart
The fluid balance chart is the record of the cumulation of the hourly totals of fluid intake and output. The nature and amount of fluid administered at different intervals should be entered. The total intake and output for every eight hours is recorded. Both sides of this form are generally used.
Discharge summary form
The discharge summary should be concise and contain only essential information, e.g. a brief history and pertinent physical findings, significant diagnostic investigation findings, the course of treatment including surgical procedures, final primary and secondary diagnoses, patients status on discharge and any advice on discharge including the follow up appointment. The discharge summary, as a routine practice, should be written prior to discharge of the patient. However, in exceptional cases, this summary should be completed within a week of the patients discharge. The treating physician and the unit head should sign the discharge summary.