Basic medical record forms and design

medical record forms

1. MEDICAL RECORD FORMS
PRESENTED BY:
SANJANA NAIR
KH.MD.P2MHA15022
MHA-3
RD
SEMESTER

2. INTRODUCTION
•Medical record forms are essential for the smooth
and efficient functioning of the hospital.
•The service provided by the medical, nursing and
other professionals to a patient is not only an
effective mean of communication but also to
serve an authentication of treatment rendered by
whom, what, why, when how and where.
•The design of forms is necessarily one of the
principal functions of a Medical Record Officer.

3. GENERAL CONSIDERATIONS
•There is multiplicity of forms utilized in every
hospital and it is essential at the outset of any
forms design program to ensure that each form
fulfils its function precisely without unnecessary
overlap with other forms completed for the same
patient.
•Each form already in use should be subjected to
severe scrutiny concerning ease of use and
satisfaction of those utilizing the form.
•The forms should be up-to-date, lack uncertainty,
and most importantly, be adequate for patient
care, and yet should be economical in use in
terms of paper, printing and equipment required.

4. FORMS
A form is a model or a style, a method of
arrangement of details, an official document with
blanks requiring completion.
Forms users are categorized mainly into two
types:
1.Those who originate the information.
2.Those who act based on the information.

5. THERE ARE TWO TYPES OF
DATA USUALLY FOUND IN A
FORM

6. STANDARDISATION OF
MEDICAL RECORD
FORMS

7. CONTD..
Other forms include registers, administrative
and legal documents such as birth, death and
other notifications, as well as statistical reports
have to be standardised.
Provisions must be made to revise forms
periodically to keep pace with changes in health
care programs and technologies.

8. AVAILABILITY OF FORMS
Sufficient budgetary provisions for forms should
be given.
Delegation of authority and responsibility for
forms procurement is necessary.
It includes the sources for forms procurement
like internal reproduction or commercial printing
and the storage and requisitioning forms.

9. DEVELOPMENT OF
MEDICAL RECORD
FORMS
When developing new forms, it is advisable to have
only a small supply prepared for trial use.
Initially forms should be simple and few in number,
should provide flexibility, and should reduce record

10. DESIGN
a.The purpose the form is to serve, and by whom it is to
be used.
b.The identification of the patient within the form
c.The retrieval of the form
d.The hospital requirements, eg, consultant
requirements.
e.The provisions made for form duplication.
f.The form number, size, paper quality, multi part forms
print, colour coding, forms colour, terminology,
standardised arrangement of data, productivity,
printing on both sides.

11. FORM INTRODUCTION AND REVISION
Introduction of numerous new forms is not advisable
because these forms are not only expensive to produce,
but also will confuse the users.
When the basic set of medical record forms has been
decided upon and introduced, samples of these forms
together with short instructions on their use, should
be kept by the health care facility.
The individual departments of the health care facility
should not be allowed to introduce new forms or to
modify any form currently in use.
There should be a record form committee, responsible
for designing and reviewing the medical record forms.

12. CONTROL OF FORMS
The authority for designing and introducing medical
record forms rests with the medical record committee for
the hospital.
The hospital staff are not authorised either to introduce
any new form or to change the size, format or content of
any of the existing forms currently in use in hospital.
If any alteration or modification is required, prior written
permission must be obtained from the medical record
committee.
Proper measures should be taken to ensure availability of
forms at all times.

13. TIPS FOR DEVELOPING
NEW FORMS
Select suitable paper, print, size, colour, terminology,
language, content, form number and quantity.
Have only a small supply of new forms for trial use
Revise forms only when necessary.
Avoid coloured forms, instead use coloured side bands if
required.
Use rubber stamps for special entries instead of new form
design.

14. CONTD..
Make the forms easily readable.
Avoid large masses of print, leave plenty of blank space.
Heading, subheadings, wordings should be precise and
accurate.
Ensure good appearance by use of good type faces.
Introduction of new forms by individual departments should be
avoided; instead the medical record committee should
authorise them.
Internationally recommended size: A4 for large and B6 for
diagnostic investigation request and report forms.
Print on both sides of the form which are used frequently.

15. THANK YOU