Journal of the Academy of Hospital Administration

Key Words: Medical record forms, Forms control, Forms evaluation, Forms standardisation

Key Messages:

• A smooth and un-interrupted supply of well-designed forms is a must for efficient medical record keeping
• Standardisation of Medical Record Forms are needed in terms of content, colour, size and quality of paper in the interest of hospital economy and efficiency

Abstract:

Patient care includes a chronological record of care and treatment , namely medical records. Accurate and adequate medical records are essential for clinical, legal, fiscal and research purposes and is based on the principle” people forget, but records remember”. Medical Records Department (MRD) has become an essential department of every hospital. Printed preforms developed by hospitals are widely used to achieve regularity and uniformity in the recording and presentation of information. A smooth and un interrupted supply of well-designed forms is a must for efficient medical record keeping. This study attempted to standardize the existing Medical Record Forms (MRF) used in a tertiary super specialty hospital. Analysis of the data revealed that forms are not standardized with regard to number, colour, content and size. Only the core forms bear numbers. Too many sizes are in use. Use of too many forms of the same colour may defeat the very purpose for introducing colour code, that of easy identification. There are multiple procuring agencies leading to multiplication of forms for same or similar purpose.

The number of forms have seen a 228% increase in the last decade. Several reasons could be ascribed to this increase like increase in the complexity and number of investigations to keep pace with the developments in medical science; various clinical departments developing and using modified versions of already existing forms e.g., Discharge Summary, in an effort to include more details. Other reasons include lack of effort to eliminate obsolete/ forms which are no longer required; separate forms for investigation request and reporting which can be combined; lack of forms control and forms evaluation in the absence of regular meetings of the Medical Records Committee; and finally lack of automation. Standardization of paper-based records is the first step and this has been recommended in terms of number, size, content, layout, thickness, colour, paper quality and inventory.

INTRODUCTION

Patient care includes a systematic and chronological record of care and treatment which necessitates the establishment of Medical Records Department in hospitals. The medical record is a storehouse of knowledge concerning the patient. It is a yardstick by which the quality of work done by the physician and hospital personnel may be measured. Despite recent interest and innovation in medical record design and use, medical records have been deemed ‘chaotic repositories of information’. The methods of data collection are almost always disparate, idiosyncratic and of doubtful consistency, having developed as much by tradition and in response to ad hoc demands as by any general or logical approach to the satisfaction of data needs. (1)

Well designed forms are needed for keeping comprehensive medical records. Properly designed forms serve to provide for easy and quick records, for compact information storage and easy and speedy retrieval of facts and figures.(2) In a large tertiary care hospital, medical record forms must be centrally controlled for efficient handling. To manage the hundreds of forms in the hospital, it is necessary to initiate a Forms control programme through the Medical Records Committee. This can be beneficial in the following: (3)

• establishment of standardised formats, sizes and quality of forms
• reduction of obsolescence
• reduction in investment in forms

On the other hand, forms evaluation (4) focuses on evaluating present documents and creating new or improved forms.

Standardization of Medical Record Forms (MRF) is needed in terms of content, colour, size and quality of paper used in the interest of the hospital economy (medical forms constitute the bulk of hospital stationery) and efficiency. In view of the escalating costs, hospital forms need to be used economically as any other consumable material in the hospital.

Around 180 types of printed forms are in use for various patient care activities at the tertiary super specialty hospital. A steady increase in the number of forms used has been recorded over the years. In the absence of forms control as advocated by the authorities, new forms are being developed and introduced by departments at random. These are also of different colours, sizes and quality. The proliferation of forms has led to a steady increase in the amount spent on printing of forms. (Thus, there is an imperative need to evaluate the demand, use and material planning of printed forms).

AIM & OBJECTIVES

The aim of the present study is to evaluate the various types of printed forms used for medical records and suggest means to standardise them for economic use.

The Objectives are to:

1. Enumerate and categories the various forms used in the hospital.
2. Ascertain the demand and supply of selected forms
3. Evaluate the form used for medical records with focus design parametres.
4. Based on the above standardise the forms in terms of content, style, colour and quality.

The study commenced with an extensive review of available literature on Medical Record Systems and Medical Record Forms. Methods described by experts in reputed organizations in designing, evaluation and control of medical record forms were studied in an attempt to understand the progress of scientific medical record keeping.

Updated information on international stationery specifications and quality were downloaded from the internet with an aim to compare the existing size and quality of forms and to determine a cost effective size and quality. The current concepts on usage of forms in hospitals were traced from the worldwide web. Printed forms are gradually being replaced by electronic formats. Latest literature on Electronic Medical Record and automated patient information system was studied to gain an insight into the requirements that have to be met to switch over from paper to electronic forms in future.

MATERIALS AND METHODS

1. A preliminary survey was carried out in the hospital to enumerate the various types of forms in use in ward areas, OPD, different clinical departments and laboratories. The process of indenting, storing and utilization of these forms instores and patient care areas was also observed. The records were also scrutinized for wear and tear of the forms due to the filing/storage process. Based on the observations, the forms were categorized and grouped.

2. Secondary data was obtained from the minutes of the meetings of the Medical Records Committee relating to the development, designing, procurement, of medical record forms. Informal discussions were held with Senior Medical Record Officer and the findings were correlated with the observations. An attempt was made to reconstruct the genesis and development of hospital forms through the four decades of existence of the hospital.

3. Sampling: For the purpose of estimation of demand and supply, the study sample comprised of all the core forms (numbered forms MR 2 to 10 of the medical records department), and 10% of the other categories of forms, selected by stratified random sampling. Thus, a representative sample of Diagnostic, Department Specific and Administrative forms selected by random number technique were included in the study. In addition, the demand and supply of the OPD card in the Central Registration Office was also ascertained, as it is one of the most commonly used forms with a large amount of resource spent on it by the stationery stores.

4. Prospective Study: The requirement of printed medical record forms were calculated for selected representative areas of the hospital. One Medical Ward, one Surgical Ward, one super specialty (Urology) ward and one Emergency ward were selected as the case mix of patients in these four wards were considered to be ‘representative’ of the hospital in patients and represented a complete spectrum of patient care.

The demand and supply of the randomly selected forms in these representative areas was calculated through a prospective study conducted for a period of three months from March to May 2004.

5. Forms Evaluation: Individual forms were studied in detail in terms of content, size, colour, quality and compared, to ascertain the variations in designing parameters among them. Evaluation of the forms and assessment of their utility was undertaken in the light of

1. Study of literature on the subject
2. In depth study of the in patient records as well as specialist clinic records to ascertain the use pattern of hospital forms
3. Pattern of consumption of various forms in the patient care areas. The consumption of forms was correlated with the work load in terms of total in patient admissions/ outpatient attendance during last three years.
4. Opinions of users through focus group discussions with medical and paramedical staff as well as staff of MedicalRecords Department and Stores organizations. The data thus obtained, was analyzed to identify the shortfalls with regard to content and design of forms as well as their utility in patient care and research and research activities in the hospital.

6. The information gathered during the above phases were integrated, analysed and methods suggested for standardization of different printed forms in use in the tertiary super specialty hospital.

RESULTS & DISCUSSION

The finding of the survey made during the initial stage of data collection to study the various types of forms in use in the hospital can be classified under the following broad categories; i.e forms used for patient care activities, and forms used for administrative purposes. These two categories can be further sub divided as shown below:

• I. Forms used for patient care
• (A) Core forms (basic medical record forms
• (a) Records kept by Doctors in words:
• 1. Face Sheet
• 2. Discharge Summary (MR-2)
• 3. General History & Physical Examination (MR-3)
• 4. Progress Record (MR-4)
• 5. Doctor’s Orders (MR-5)
• 6. Consultation Record (MR-9)
  (b) Operative Notes:
• 7. Operation Record (MR-7)
• 8. Anaesthesia Record
  (c) Records kept by nurses:
• 9. Intake Output Chart (MR-6)
• 10. Temperature, Pulse, Respiration Chart (MR-10)
• 11. Nurses Daily Record (MR-8)
• 12. Consent Form

(B) Diagnostic forms:

• Laboratory Forms, including Hematology, Microbiology, Clinical Chemistry
• Tissue report forms (Histopathology)
• Other investigation report forms e.g., X-ray, ECG etc.
• Special Investigation Report Forms e.g., Radio isotope studies, MRI, Pulmonary Function test, Clinical Immunology. Hormone assay, Bone densitometry request forms etc.

(C) Department (discipline) specific forms

• For outpatients – Specialty Clinic Proforma, e.g., Diabetes Clinic proforma in Endocrinology, Liver Clinic Proforma in Gastro enterology etc.
• For inpatients – Special forms for NICU, Nephrology, Orthopaedics, Urology, Paediatric Surgery etc.

II) Forms for Administrative purposes (e.g., Admission slip, Medical & Fitness Certificate, Reimbursement forms, estimates etc.)

Table 1: Number and types of forms in use in the hospital during last four decades

Year	O P D Records	% Increase	Inpatient Records	% Increase	Administrative Forms	% Increase	Total No of Forms
1964	2	-	22	-	5	-	29
1974	2	-	35	60	10	100	47
1984	3	50	48	37	14	40	65
1994	5	67	49	2	27	48	78
2004	35	600	96	104	47	74	178

Fig. 1: Graphical Representation of the number of
Medical Record forms in use over the last four decades

II) Forms for Administrative purposes (e.g., Admission slip, Medical & Fitness Certificate, Reimbursement forms, estimates etc.)

It is evident from table 1, that there is a tremendous increase (228%) in all categories of medical records of forms used in the hospital during last four decades. There are a total of 22 sizes of different types of form as shown in table 2, with minor differences in length and width Similarly, the range and quantity of weight of medical record forms used in the hospital are shown in table 3.

It was found that patient identification data are not uniform on different forms. Further the sequence in which the identification particulars appear also differ in the Discharge Summary, History Form and TPR Chart. As a step towards standardizing the design of forms it is necessary to have uniform sequence of identification particulars of the patient on all inpatient record forms.(5) It was observed that there is no consistency in the placement of the various columns on the different investigation forms. In some forms the form title is on the top middle, in others it is on the top left, in some forms the instructions are printed in the middle of the form, In others it is printed at the bottom. The signature block of the requesting doctor is on the bottom right in some investigation forms, bottom middle in others and bottom left in yet others.

Majority of the forms are white, however forms of other colours are also available. Presently there are four types of blue forms (Hormone analysis – Dept of Reproductive Biology; Hormone Assay – Dept of Endocrinology, Fluid Chemistry - Dept of Lab Medicine, Bacteriology – Dept of Microbiology), besides two yellow forms and two pink forms. This can cause confusion to the requesting physician in a busy area of the hospital where all of these forms are used e.g., Medicine OPD. It was also observed that there was a marked variation in colour between lots of forms supplied by the vendors at times.

Table 2: Various Sizes of Forms Used in the Hospital

Serial No.	Size
1	9” x 11” (22 CM X 27 CM)
2	51/2” x 9” (13 CM X 22 CM)
3	51/4” x 7” (12 CM X 17 CM)
4	8” x 9” (20 CM X 22 CM)
5	9” x 22” (22 CM X 55 CM)
6	103/4” x 15” (27 CM X 38 CM)
7	111/2” x 18” (29 CM X 45 CM)
8	20” x 30” (50 CM X 74 CM)
9	20” x 12” (40 CM X 30 CM)
10	20” x 6” (40 CM X 15 CM)
11	20” x 20” (50 CM X 50 CM)
12	103/4”x 171/2” (27 CM X 44 CM)
13	141/2” x 19” (35 CM X 47 CM)
14	10” x 13” (25 CM X 37 CM)
15	61/4” x 3” (16 CM X 08 CM)
16	17” x 263/4” (42 CM X 67 CM)
17	81/2” x 131/2” (21 CM X 33 CM)
18	131/4” x 17” (33 CM X 42 CM)
19	3” x 5” (08 CM X 13 CM)
20	51/4” x 9” (12 CM X 22 CM)
21	71/2” x 9” (19 CM X 22 CM)
22	11” x 11” (27 CM X 27 CM)

From Table 4 it is seen that 100% demand is generally not met by the Stationery Store. However, this shortfall in supply, on enquiry from the concerned areas, did not pose any real difficulty to the users. It was also seen that forms were on many occasions indented at intervals of two and even three months. It was further observed that if a particular form was unavailable in the stationery stores on a particular month, there was no urgency shown by the users to send demand for the same later that month or even next month. These are pointers to the fact that the demands made are inflated and not based on monthly consumption or any other scientific criteria. Under the circumstances, the stationery storekeeper exercises his control and arbitrarily reduces some quantity from the demand, purely on intuition and experience.

Table 3: Quality of forms in Terms of stock papers and their weight in grams per square meter (GSM)

Serial No	Stock Paper	GSM	Type of Form
1	18”x 22”(45CM x 55 CM)	75	All White Forms of 9” x 11” size All White Forms of 9” x 8” size All White Forms of 9” x 51/2” size
2	18”x 22”(45CM x 55 CM)	75	All the Coloured Forms
3	17”x 27”(42 CM x 68 CM)	75	All forms of 81/2” x 131/2” size
4	20” x 30”(50CM x 75 CM)	75	Cytopathology Investigation Form
5	22” x 28”(55CM x 70CM)	200	All cards (OPD card, Anaesthesia record card, Diagnostic Index, Tracer card etc.)
6	111/2”x18”(29CM x45CM)	300	Some Specialist Clinic Files, e.g., Endo

Table 4: Demand and Supply of forms during study period(March-May 2004)

Serial No.	Form Title	Demand	Supply	Percentage supply
1	Discharge Summary	500	500	100%
2	General History & Physical Exam	8700	8200	94.25%
3	Progress Report	7300	7300	100%
4	Doctors Orders	4400	900	20.45%
5	Intake Output Chart	1600	1600	100%
7	Nurses Notes	8500	8100	95.29%
8	Consultation Record	4300	-	0 %
9	Diet requisition	300	200	66.66%
10	X-ray request	2400	2400	100%
11	ECG request	2200	2200	100%
13	Consent Form	300	200	66.66%
14	Blood Requisition	3700	3700	100%
15	Bacteriology Investigation	5000	5000	100%
16	Haematology Form	6200	2200	35.48%
17	Clinical Pathology (Fluids & excretions)	2200	700	31.81%
18	Fitness Certificate	300	300	100%
19	Admission Slip	2300	2300	100%
20	OPD card	2,40,000	1,36,000	56.66%

Fig. 2: OPD Attendance	Fig. 3: In Patient Admissions

It is seen (fig 2,3) that there has been a steady increase in the OPD attendance as well as the number of inpatient admissions over the last three years. This steady increase in patient care activities is commensurate with the corresponding increase in consumption of medical record forms.

The present study reveals that no attempts have been made at standardization of hospital forms in the four decades that the Hospital is functioning. Standardization needs to be carried out in the following broad areas:

1) Standardization of the Number and Types of Forms – There are a large number of forms for similar purposes in use in tertiary hospital. The Medical Records Committee has to take the initiative to standardize forms. A coordinated effort of physicians, nurses & medical record personnel, is required to standardize forms in a hospital. Those forms which are of an inescapable nature, can be retained, contents of some forms can be combined and those found useless or irrelevant, discontinued. This way, the number of forms can be brought down to the minimum. In this connection the use of one type of X-ray form with rubber stamps indicating different purposes (MLC/Non MLC); a Common Investigation Sheet to replace the Investigation sheets developed by practically all clinical departments; wider use of the Common Discharge Summary with an additional information sheet for the specialty concerned; combining of MRI requisition with Report, Nuclear medicine investigation requisition with Report may be cited.

2) Standardization of Content (6) – The information needed from the form is the first requirement in deciding the content of the form. A form number identifies the form, serves as a reference in a design procedure and helps in issuing quantities of the form from the store on request. Since the form title and number are part of the form identification, they should be placed together in one standard position. There is an urgent requirement of allotting form numbers to the forms in use at the hospital. All the data that must go on the form must be listed and classified into logical groupings of items that have common relationship, and then sequence the groups in a logical flow.

3) Standardization in terms of Size (7) Desirable from the point of view of economy and practicability. A4 size can be taken as a standard size for the basic forms and 8 1/2” x 5 1/2” size taken as standard size for the majority of the investigation forms, Admission slip, Discharge slip, ECG requisition etc. as it too can be derived from A4 size.

4) Standardization in terms of Colour – Standardisation in terms of use of colour in forms should be left to the Medical Records or Forms Committee. Basic philosophy of using coloured forms is to identify the forms used in different areas of the Hospital. However, indiscriminate use of colour in medical record form can be counterproductive.

5) Standardization in terms of Quality of Paper (8,5)- Quality or weight of paper to be used for printing forms will depend upon, handling, retention period and method of storage. In the tertiary super specialty hospital, the inpatient records are kept for 10 years and the medico legal case records are stored indefinitely. The quality of paper should be such that the records should be in good condition at the end of the prescribed retention period. Based on this the following qualities of paper were worked out for the medical record forms – All medical forms, white & coloured, printed on single side / both sides - 75 GSM -All card type medical record proformae (e.g, OPD Card, Tracer card etc.) – 200GSM

6) Standardization of Inventory -Standard inventory control of printed forms is not practicable in the hospital because there are multiple agencies for purchasing printed forms. One single agency needs to be earmarked for the procurement of the forms irrespective of the place of use and source of funds for their procurement. Buffer stock and Reorder level for each form needs to be calculated to prevent potential stock out situations.

CONCLUSION

Information is usually the first need of management to have greater control on costs and improve efficiency. These needs vary according to the type and objective focus of the hospital or healthcare provider. It is essential to re-establish and energize the dormant Medical Records Committee with a view to keep a check on the run away trends for introduction of new forms, and weed out obsolete ones. Standardization of forms with regard to number, type, size, colour, content, quality, thickness is a sine qua non for effective patient care documentation and good management.

REFERENCES

1. J. Petrie and N. McIntyre (eds), ‘The Problem Oriented Medical Record: Its Use in Hospitals, General Practice and Medical Education’ (Edinburgh, Churchill Livingstone, 1979), p.2.
2. Sharma L. ‘A Study Of Medical record Forms at All India Institute Of Medical sciences Hospital, New Delhi’ : Thesis : Dept of Hospital Administration, AIIMS, 1984(unpublished)
3. Howard S Rowland, Beatrice L Rowland, ‘Hospital Management, A Guide to Departments’, Aspen, 1984
4. Elias M Awad, Richard D Irwin, ‘Systems Analysis and Design’, Homewood, Illinois, 1979
5. Vanderbilt University Medical Centre, 1161 21st Avenue South, A-1223 MCN,Nashville, TN 37232-2183, (http://vumcpolicies.mc.vanderbilt.edu/)
6. Louisiana State University Health Sciences Center - Shreveport Hospital Forms Review And Approval Process, Policy number: 6.14, Effective Date: 11/01/03
7. International Standard Paper Sizes by Markus Kuhn created 1996-10-29—last modified 2003-12-23 – www.printindustry.com

A. Chattoraj¹, S. Satpathy², R.K. Sarma³

¹ Research Pool Officer, Office of the Director General Armed Forces Medical Services, New Delhi

² Associate Professor, Dept of Hospital Administration, AIIMS, New Delhi

³ Director, NEIGRIHMS, Shillong.