Assignment: A standardized format for the use of forms in the paper record and documentation screens in the electronic health record is necessary in order to enable accurate documentation and ease of

Assignment, Rubric, & Lesson Content

TIP of This Week Assignment:

Welcome to week 5! This week's topic is on the control of health record forms. Did you know that it is important to manage the forms within a healthcare facility. When managing forms, we are making sure everyone is using the most up-to-date form, ensuring appropriate data is being captured as required by standards organization, federal and state regulations, and hospital policies, and making sure we are not recording duplicate information that is being captured by other forms. The control of health record forms will vary depending on whether the facility is paper vs electronic. For your assignment this week, create a policy on organization-wide guidelines on forms control. You can utilize the policies you find under module 1 or research policies on your own.

Assignment:

A standardized format for the use of forms in the paper record and documentation screens in the electronic health record is necessary in order to enable accurate documentation and ease of location of information, whether in paper or electronically for patient care as well as other administrative uses of the record.

Select policies, procedures and guidelines provided for benchmarking in Module 01 under Benchmarking Resources based on appropriateness to this topic, or you may research policies, guidelines and standards on your own to use as a benchmark.

Requirement:

Review your selected policies, procedures and guidelines and select the information after comparing those resources that you will include in your policy and write your policy on organization wide guidelines on forms control. Consider how new documentation capture tools can be recommended, approved and communicated to the health care providers.

The completed typed policy should be 1-3 pages. If you use a source for the policy (Please format in a work policy & procedure see example below), state the source at the end of the policy under a heading titled references.

Submit your completed assignment by following the directions linked below. Please check the Course Calendar for specific due dates. Save your assignment as a Microsoft Word document.

Save your assignment as a Microsoft Word document

Your rubric for this week is below:

Scoring Rubric:  Policy on Forms Control

Lesson Content:

AHIMA. "Data Quality:The Impact on Healthcare and HIM". AHIMA's 76th National Convention and Exhibit Proceedings, October 2003. Link to article. (https://content.learntoday.info/Learn/HI435_Summer_12/site/Media/Module_05_Data_Quality_the_Impact_on_Healthcare_and_HIM.pdf)

Principles of Template Design

A well-designed form improves the reliability of the data entered on it. A form should be designed to collect information in a consistent way and to remind providers of information that needs to be included. Many paper record forms consist of a single sheet. Other specialty forms, such as a unit-set form or a multipart form, have multiple-sheet forms preassembled in either carbon or carbonless sets. With spot carbons in unit-set forms, only part of the information on the original is visible on the copy. For example, when the face sheet is the first page of a unit set and is printed on the computer, the carbon can be positioned so that the copy for a clinical department would have only the patient identification information and not the financial information.

Continuous-feed forms use a series of forms separated with perforations that can be printed by a printer without having to load the paper for each form printed. The forms then can be separated and distributed. Continuous-feed forms can be used for both single sheets and multi-set forms.

Most forms include similar basic components, and all should contain at least a heading to describe the contents and purpose of the form, instructions on how to complete it, and spaces to enter required and optional information. General guidelines to follow when designing forms include the following:

• The form should be easy to complete.

• Instructions on completion and use of the form should be included.

• The form should have a heading with a title that clearly identifies its purpose.

• The facility’s name and address should appear on each page of the form.

• The name, patient identification number, and other identifying information should be present on each form. Most facilities now use bar coding technology as identifying information.

• Bar coding also should be included in indexing the form for random access in an optical scanner or microfilming system. Bar codes are generally printed directly on the document or on a label affixed to the document.

• The form number and date of revision should be included to ensure that the form being used is the correct and most current version.

• Outdated forms should be recalled and eliminated.

• The physical layout of the form should be logical. When a clerk is entering information as the patient gives it, for example, the form should be organized to match the way the information is requested.

• Personal and address data and other items of information that relate to one another should be placed together (for example, the patient’s city, state, and zip code).

• Font selection should be standardized. Some experts recommend all capital letters.

• Additional margin space should be provided for hole punches to allow the documents to be placed in folders or chart holders. The holes may be on the left-hand side of the form, at the top, or both, depending on the types of folders or binders used.

• Ruled lines may be used to outline sections of forms to allow for easy entry of data or to separate areas of the form.

• Check boxes and fields can be used to provide space for the collection of data.

Careful consideration also should be given to not including information on the backs of forms since it may be overlooked. Facilities that are imaging paper records must have the bar-coded patient identification information on the back of the form to ensure proper indexing into the imaging system. Even though scanners can scan both sides of a document, the ability to index and thus access the information must be ensured.

Electronic Forms Management

Facilities must develop strict guidelines and processes for forms control. Word-processing programs and programs specifically designed for forms design have made the process easier than in the past. Providers often design their own non-approved forms, which may appear in the paper record when it arrives in the HIM department. These unauthorized forms affect the patient care process as well as procedures in the department. The person who designed the form may be unaware of the interrelated processes that are affected by changing it. A bar code identifying the type of form would not be available for forms that have not gone through the approval process.

Forms control systems must:

• Provide for the development of forms according to established guidelines

• Control the printing and use of forms

• Guide providers in designing forms according to established guidelines

• Prevent staff from changing or designing forms that duplicate existing forms or could be combined into other forms

Forms control is critical to the transition toward hybrid and EHR systems. The transition to electronic records usually begins with creating a hybrid health record by using an imaging system to gather information about existing forms and to ensure that all forms can be properly scanned and indexed. Without indexing, the information cannot be easily retrieved. The forms control process also should establish processes for forms inventory, forms identification, forms analysis, and forms purchasing.

Forms Inventory

The first step in the forms control process is the forms inventory. This process involves gathering each form and all of its editions to ensure that the most current version is used. A subject file is a good idea for bringing together all the forms used by each of the areas, such as all admissions or registration forms, all operative forms, and all nursing forms. Organizing in this manner can prevent new forms from being developed when current forms have the needed information, assist in finding ways to combine forms with related information, and serve as a reminder that information changed on one form must be changed on related forms.

Forms Identification

The second part of the forms control process is forms identification. This process involves assigning each form a distinct title that reflects its use. In paper systems, a forms number is also assigned to indicate that the form has been approved. The date and the source department are usually included with the number. Bar coding and labels with complete bar-coded information about the form are becoming more prevalent as facilities prepare for the computerization of forms. A numerical listing of forms by the forms identification number should be maintained.

Forms Analysis

Forms analysis involves the continuous review and revision of forms. The forms analysis process is often initiated because of procedural problems, such as when providers are not receiving the information they need to do their work. Forms assist in guiding processes and ensuring that complete information is obtained and recorded. Flowcharting the development and distribution of the forms is helpful in determining whether a form is still useful, whether the information it contains is current, and whether it meets the current requirements of the facility.

Forms Purchasing

Purchasing and printing comprise the fourth part of the forms control process. A policy should be in place stating that forms cannot be ordered or reordered without approval of the forms committee or some other group or individual responsible for purchasing and printing approval. Some facilities now use just-in-time production of forms. Just-in-time production is a procedure where copies of forms can be printed at the patient care area rather than having to maintain a large inventory of paper forms. This inventory of forms becomes obsolete when any change is made to the form. This eliminates the possibility that an outdated form is available for use in a health record.

Role for Data Recording During Systems Downtime

Paper forms are critical for data recording in the health record during system downtimes and outages. Forms should be made available for printing in the patient care areas in instances of systems downtime. This allows for easy access to the forms when necessary and also provides a mechanism to manage and update the forms and ensure that only approved forms are available for providers to enter documentation for the health record.

What Does a Health Record Need to Be a Good Data Collection Tool?

Managing health record forms is an important aspect of the electronic health record, and many of the same basic concepts used with paper forms need to be applied to electronic health forms. Many hospitals are using the paper medical record forms on the nursing units and then scanning them into the electronic health record. According to an article from the AHIMA website, King and Keifer stated that the negative effect of manual forms management affected patient care and safety (King and Keifer, 2007). They said that average care givers spend 35% of their time on processing tasks such as producing, accessing, routing, and handling forms. They went on to state that manual data entry, illegible or outdated forms, and hard-to-read embossers can lead to errors of interpretation, thereby compromising patient safety. Also, the inability to locate the correct form at the correct time not only reduces the time caregivers dedicate to patient care, but also can have detrimental effects for an institution.

By automating the tasks that are involved in forms processing, hospitals can virtually go paperless and eliminate the costs associated with paper forms. With forms automation, the most current version of each form is always available and can be printed on demand, eliminating the use of inventory in the hospital.

When forms are designed to be used as a document that is scanned into the electronic health record, there are several factors that need to be considered. Standards for a legal health record, as well as a sound forms approval process, need to be adhered to. A hospital's Forms Committee will need to review these new forms to see if it is a duplication of another form, and to check on the format to make sure it meets the necessary standards set for it to become part of the legal health record. Consistent placement of information such as the patient's name, encounter or admission date, the name of the form, and the date of approval should be on each form. The policy may also outline the color of paper that is acceptable to use and the font size. Bar coding will need to be assigned and affixed to each document that will be scanned.

Members of the Forms Committee should include representatives from the clinical side of the hospital and from business and technology. Often times the Manager or Director of Health Information is the chair of this committee. Providers asking for a new form to be approved may be invited to the meeting to present their form and give an explanation of the purpose.

King, Elaine, MHS, RHIA, CHP, and Keifer, Linda. Forms Automation:The Best Kept Secret in Health Information Management. (October, 2007.) Retrieved from www.ahima.org.