ALL SAINTS UNIVERSITY

LANGO
DEPARTMENT OF MEDICAL RECORDS AND HEALTH
INFORMATICS
Course Unit: MEDICAL RECORDS MANAGEMENT
III&IV
Course Level: Undergraduate
Course Unite Facilitator: Mr. Robert Pius Okello
M.EDCand;MPAM,PGD.ED(NU);MPAM,PGD.PAM(TU);BS.IT,Dip.ICT(Asul);C
ert.Admin Law(Mak)

DESIGNING MEDICAL RECORDS FORMS AND FOLDERS

Introduction

All health facilities have the responsibility to develop medical

record forms as per their requirements. Thoughtful designs of the
forms will become part of the medical record, that will provide a
more readable, useful, and less bulky document. Forms can
accomplish several purposes: they can reduce writing time and
standardisation of information results from their use.

The first and most important step in form designing is to

determine the purpose of the form. 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.

Principles of forms designing

In the development of a new form, it is advisable 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 method of choice. Forms
should be kept simple and the variety must be few in number to
provide flexibility and reduce bulky record. All discontinued forms
should be removed from the stockroom or supply area and
destroyed.

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 Before a new form is developed or an existing form is revised, the
following steps can be used to compile the necessary facts and to
determine what, if any, improvements should be made.

The Principles for Designing a Standard Forms

 A uniform size of paper should be used. Although standard size (8
½ -inch - by 11-inch) paper is most commonly used, 8-½ -inch- by
-5 ½ -inch papers could be used to reduce waste.
 A uniform binding should be maintained, either on top or side.
 A uniform margin that is based on the binding edge should be
maintained.
 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.
 Good quality paper should be used. If both sides are to 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 form that is not used regularly

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. Keep in
mind also that different colors of paper and ink will affect
photocopying and microfilming in different ways.

Duplicating methods

Several persons or departments often need similar patient data.

In such situations it is well to consider the possibility of a
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 multipart form or a method to produce multiple copies. Multipart
forms should be used whenever possible to

1. Save time and labor;

2. Avoid errors
3. Promote rapid intra hospital communication of essential
data; and
4. Meet the need for extra copies.

The effectiveness of legible carbon copies is limited to two

or three copies. Carbon copies may be of three types:

 Loose carbon inserted between forms. The inserting and removing

of carbon paper makes this method time-consuming. In addition,
care must be taken to ensure that the information on all copies is
lined up exactly or entries will appear above or below the space
indicated.
 Snap-out or interleaved forms with one-time carbon previously
inserted by the printer. Snap-out forms are widely used for
reports of operations, discharge summaries, and dictated reports
when copies are needed.
 Forms with carbonized backing are particularly effective for
carbonizing specific portions of forms. However, the black
carbonized portion rubs off and is more difficult to handle. This
may be a disadvantage to consider.
 Stencils or master copies - this method is used to produce more
copies than is possible with the above methods. Care must be
taken to avoid methods which result in copies that will fade or in
which legibility is poor.
 Photocopy equipment - this method is used to produce exact
copies. Eliminating the need for a stencil saves time and labor.
Out Patient Records

Hospitals, which have an organised out-patient department, may

maintain as many as twenty or more speciality clinics for out-
patients. The records that are compiled in this setting should be
compatible in size and format to those used for outpatients and
inpatients in the facility. Each patient registered as an outpatient
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should have an initial history and physical examination, which
should be brought up to date at regular intervals. Every clinic visit
should be noted, including date, clinical finding, treatment, and
names of those examining or caring for the patient.

Out- patient records are compiled in the outpatient department

and should conform in size and form to the records used for
hospitalised patients. On the subsequent clinic visits, noting as to
findings and treatment should be made on the continuation note
sheets. If the patient is admitted to the hospital, his outpatient
record should be filed with the inpatient record as a unit,
reflecting continuous medical care. These records should be
checked as closely as those for hospitalized patients for accuracy
in dates, time, spelling, and hospital numbers.

Information card

The primary purpose of information card is to collect the basic

identifying information of patient. Identification data is ordinarily
obtained at the time of patient registration. Therefore the patient
medical file must include complete and correct identification data
including: the hospital number, the patient’s name, and gender,
date of birth (age), address, telephone number, cell phone
number, e-mail address and relative’s name.

Outpatient main record

The out-patient record consists of outpatient (OP) main card and

continuation sheet. The OP main card is basically used as a first
record of document (Fig.4.2). This contains the identifying
information of a patient with contact phone and cell phone
numbers and e-mail address. The purpose of this sheet is to assist
the doctors in getting the history and complaints of the patient
thereby establishing a diagnosis on which to base the care and
treatment of the patient. The essential facts should be given in a
concise and progressive manner.

In addition basic tests like urine sugar, blood sugar and other
physical tests like blood pressure of the patient are also recorded.
Proper International Classification of Diseases (ICD) code should
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 be recorded by the doctors in the space provided for the purpose
after finalising the diagnosis of the patient. When the outpatient
main card is fulfilled, additional sheets can be added to continue
the progress and treatment of the patient. This continuation sheet
is added to the record according to the need.

Specialty Surgery Record

Speciality surgery records are attached along with the other in-
patient records according to the speciality department to which
the patient gets admitted. For example:

 Retina surgery Record

 Cataract / IOL surgery Record
 Pediatric ophthalmology Intra operative Record
 Strabismus Surgery Record
 Glaucoma Surgery Record
 Orbit and Oculoplasty Surgery Record
 General Anesthesia Record
Color coding of record folders

Color coding

This the use of color on folders to aid in the prevention of

misfiling and in the location of misfiled records. Color bars in
various positions around the edges of folders (known as blocking)
create distinct patterns of color in various sections of the file. A
break in the color pattern in a file section signals a misfiled
record.

Color coding is most effective when used in conjunction with

terminal digit and middle digit filing, although it is said that
workable color-coding systems can be used for straight numerical
filing.

Color folders

Based on the type of specialty department the color folders are

also attached as a folder cover with the case sheet. This folders
are in different colors. For example:

 Retina Folder (Light Blue)

 Cornea (Light Green)
 Cataract & IOL (Yellow)
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 Orbit (Thick Green)
 Pediatric (Thick Reddish Brown)
 Uvea (Light Biscuit Brown)
 Glaucoma (Pink)
 General (Grey)

Discharge summary sheet

When patients are discharged, discharge summary is given along

with the final receipt. The discharge summary is a concise
recapitulation of the reasons for hospitalization, significant
findings, procedures performed, course of hospitalization, and
condition of patient on discharge, and instructions given to the
patient or family relating to physical activity, medications, diet,
and follow-up care. The discharge summary sheet varies by colors
and information according to the specialty.

The following summary sheets are given as samples used against

the specialty mentioned below:

i. Cataract/IOL discharge summary sheet

ii. Retina summary Book
iii. Paediatric Cataract summary Book
iv. Discharge Summary
v. Summary

A medical record must be maintained on every person who has

been admitted to the hospital as an inpatient, outpatient or as an
emergency patient. The medical record documents the medical
and surgical history of the patient. Each hospital has the
responsibility to develop medical record forms to fit its needs.
Responsibility for designing medical record forms is delegated to
the hospital forms committee. Although a variety of styles of
medical record forms are used in hospitals throughout the
country, certain basic essentials must be included if the hospital
is to maintain accreditation standards.

Key points to remember

 A medical record must be maintained on all the patients who
have been admitted in the hospital either as an Inpatient, as an
emergency patient or visit the hospital as an outpatient.
 In the development of a new form, it is advisable to have only a
small supply of forms prepared for trial use.

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 All discontinued forms should be removed from the stockroom or
supply area and destroyed.
 Remember that standard–size forms are always less expensive,
facilitate filing preclude loss, which is often the case with irregular
paper sizes.
 When feasible, using a rubber stamp on an existing form can
eliminate the need for special form that is not used regularly.
 Since cost is also a factor in continually revising and printing
small quantities of forms, photocopying might be the reproduction
method of choice.
Students Exercise
Sample Questions
1. Explain the four purposes for maintaining Outpatient
Records in a hospital?
2. Summarize the information contents of each of the following
medical record forms:
i. Information card.
ii. Consent form for surgical / medical procedures.
iii. Surgery record.
iv. Discharge summary book.
3. State the first and most important step in designing a
standard forms.
4. Explain the basic principles in the development of good
medical record forms.

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