Standardising Medical Records Forms: A Study at a Tertiary Super Specialty Hospital
Author(s): A. Chattoraj, S. Satpathy, R.K. Sarma
Vol. 17, No. 2 (2005-01 - 2005-12)
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:
- Enumerate and categories the various forms used in the hospital.
- Ascertain the demand and supply of selected forms
- Evaluate the form used for medical records with focus design parametres.
- 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
- Study of literature on the subject
- In depth study of the in patient records as well as specialist
clinic records to ascertain the use pattern of hospital forms
- 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.
- 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
- 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.
- 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)
- Howard S Rowland, Beatrice L Rowland, ‘Hospital
Management, A Guide to Departments’, Aspen, 1984
- Elias M Awad, Richard D Irwin, ‘Systems Analysis and
Design’, Homewood, Illinois, 1979
- Vanderbilt University Medical Centre, 1161 21st Avenue
South, A-1223 MCN,Nashville, TN 37232-2183, (http://vumcpolicies.mc.vanderbilt.edu/)
- Louisiana State University Health Sciences Center -
Shreveport Hospital Forms Review And Approval
Process, Policy number: 6.14, Effective Date: 11/01/03
- 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.
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:
- Enumerate and categories the various forms used in the hospital.
- Ascertain the demand and supply of selected forms
- Evaluate the form used for medical records with focus design parametres.
- 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
- Study of literature on the subject
- In depth study of the in patient records as well as specialist clinic records to ascertain the use pattern of hospital forms
- 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.
- 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
- 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.
- 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)
- Howard S Rowland, Beatrice L Rowland, ‘Hospital Management, A Guide to Departments’, Aspen, 1984
- Elias M Awad, Richard D Irwin, ‘Systems Analysis and Design’, Homewood, Illinois, 1979
- Vanderbilt University Medical Centre, 1161 21st Avenue South, A-1223 MCN,Nashville, TN 37232-2183, (http://vumcpolicies.mc.vanderbilt.edu/)
- Louisiana State University Health Sciences Center - Shreveport Hospital Forms Review And Approval Process, Policy number: 6.14, Effective Date: 11/01/03
- 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.