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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 128-133 |
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A study to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, so as to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end users
Rajesh Harsvardhan, Arushi Jaiswal, Prerna Kapoor, Rudrashish Halder
Department of Hospital Administration, SGPGIMS, Lucknow, Uttar Pradesh, India
| Date of Submission | 27-Jun-2022 |
| Date of Decision | 25-Jul-2022 |
| Date of Acceptance | 10-Aug-2022 |
| Date of Web Publication | 2-Sep-2022 |
Correspondence Address:
Rajesh Harsvardhan
Fourth Floor, New Library Complex, SGPGIMS, Lucknow - 0226 014, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jigims.jigims_32_22
Background: Effectual management of medical records (MR) is a prime component in health-care delivery organizations. A standardized medical form facilitates for obtaining comprehensive information along with appropriate documentation for swift and efficient retrieval of information pertaining to the quality of patient care. It seems astounding that hitherto, there have been no set standards/criteria to evaluate MR forms. With this backdrop, the study aimed to rationalize MR forms in use at SGPGIMS in conformance with the inter/national guidelines as a stride toward quality improvement.
Aim: The aim of this study was to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end user.
Objectives: The objective of this study was to obtain the health-care (clinical and medical) record forms in use at SGPGIMS hospital. To compare the health-care (clinical and medical) record forms in use at SGPGIMS hospital with inter/national guidelines through the appropriate designed tool, i.e., (structured checklist). To recommend an evidence-based modification in health-care (clinical and medical) record forms based on analysis of data obtained, to ensure structural and contextual uniformity while updating the same for the prospective in-house users, if required.
Methodology: A descriptive study was carried out at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, with a study sample of preidentified health-care (clinical and medical) forms which are the core forms to all the departments of SGPGIMS, hospital. A customized validated tool kit (structured checklist) was designed in conformance with inter/national guidelines to assess the preidentified health-care (clinical and medical) forms.
Results: The Medical Certificate of Cause of Death Form was found to have the highest compliance rate of 90.5% with the given set of parameters among the preidentified forms, while the Medication Chart and Assessment Form have noncompliance rates of 61.1% and 58.1%, respectively, with the given set of parameters. Rest other preidentified medical forms have the noncompliance rate of <50% with the given set of parameters of customized tool kit.
Conclusion: Since this was the foremost study conducted, it was observed that there was a need to rationalize the MR forms by implementing the observations made, so as to ensure structural and contextual uniformity by the end users.
Keywords: Medical record, medical record forms rationalization, medical record forms, quality parameters in medical record forms
How to cite this article:
Harsvardhan R, Jaiswal A, Kapoor P, Halder R. A study to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, so as to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end users. J Indira Gandhi Inst Med Sci 2022;8:128-33 |
How to cite this URL:
Harsvardhan R, Jaiswal A, Kapoor P, Halder R. A study to rationalize the health-care (clinical and medical) record forms in use at SGPGIMS hospital, in conformance with inter/national guidelines, so as to ensure structural and contextual uniformity while updating the same for prospective in-house consumption by the end users. J Indira Gandhi Inst Med Sci [serial online] 2022 [cited 2023 Mar 27];8:128-33. Available from: http://www.jigims.co.in/text.asp?2022/8/2/128/355319 |
| Introduction | |  |
A medical record (MR) is the chronological documentation of medical treatment and other health care delivered to a patient by professional members of the health-care team. It is an accurate, prompt recording of the team's observations about the patient, the patient's medical progress, and the results of treatment.[1] MR forms can either be in paper or be in electronic form or both serve as a document of ensuing medical tests, diagnoses, and treatments to an individual.
MR form is the essence for the smooth and efficient functioning of the hospital. It is a model or a style, a method of arrangement of details, and an official document with blanks requiring completion. It is an essential tool of documentation that permits uniformity in the documentation. Consistent, current, and complete documentation in the MR form is an essential component of quality patient care.[2]
The first major attempt to standardize MRs in the UK came in 1965 with the publication of the Tunbridge report. This produced some of the standard hospital MR forms we use today.[3] Generic MR-keeping standards define a good practice for MRs and address the broad requirements that apply to all clinical note keeping. These standards were developed by the Health Informatics Unit of the Royal College of Physicians, following a review of published standards and wide consultation. They were first published in 2007 in clinical medicine.[4]
Effective records management practice is a vital element of management of any health-care service-providing organization. Despite the important role played by records management, there is evidence to suggest that many of the health-care service organizations pay a little attention to standardized management of records.[5]
This study aimed to rationalize MR forms in use at SGPGIMS in conformance with the inter/national guidelines, with the objectives: (1) To compare the health-care (clinical and medical) record forms in use at SGPGIMS hospital, with inter/national guidelines through the appropriate designed tool, i.e.,(structured checklist), (2) To recommend an evidence-based modification, in health-care (clinical and medical) record forms based on analysis of data obtained, to ensure structural and contextual uniformity while updating the same for the prospective in-house users, if required.
| Methodology | | |
A descriptive study was carried out at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, from August 2020 to May 2021. With convenience sampling technique and keeping in view the variation among the health-care (clinical and medical) forms of the different departments of SGPGIMS hospital, only the preidentified health-care (clinical and medical) forms were included in the study, which are the core forms to all the departments of SGPGIMS.
Following preidentified health-care (clinical and medical) forms are included in the study:
- Patient Registration Form
- Assessment Form
- Admission and Discharge Form
- Requisition Form for Consultation
- Progress Notes and Orders
- Nurse Record for Indoor Patients
- Intake Output Chart
- Vital Chart
- Informed Consent Form
- Investigation Chart
- Medication Chart
- Prescription Form
- Leave against medical advice form
- Medical Cause of Death Certificate Form.
A customized tool kit in form of the structured checklist is prepared in conformance with the following inter/national guidelines undertaken in this study: WHO (guidelines for MR practice), WHO (MR manual), WHO (guidelines for MR and clinical documentation), NCQA (guidelines for MR documentation), JCI 6th edition, NABH 4th and 5th edition (IMS), and Electronic Health Records standards 2013 and 2016.
The structured checklist comprised the following components: Patient Particulars, Clinical Particulars, Signing Authority Particulars (health-care professionals), and General Form Particulars with parameters under each component of the checklist. The preidentified health-care (clinical and medical) record forms were assessed through the structured checklist with scoring criteria as mentioned vide infra:
Data analysis was performed using SPSS version 26.0. SPSS (statistical package for social sciences) is a statistical analysis software that was developed in 1968 by N. H. Nile, D.H. Bent and C. H. Hull.
| Results | | |
The parameters under the four components (Patient Particulars, Clinical Particulars, Signing Authority Particulars (health-care professional), and General Form Particulars) of the customized checklist were varied as per the individual MR form, and deficiencies were observed with the in-use MR form.
Based on the gap analysis [Table 1] and additional inputs by key stakeholders, modifications were done in the existing MR forms at SGPGIMS, to rationalize them with inter/national guidelines pertaining to MR forms. | Table 1: Assessment of preidentified medical record forms with the parameters of customized checklist
Click here to view |
The Medical Certificate of Cause of Death Form was found to have the highest compliance percentage of 90.5% with the given set of parameters among the preidentified forms.
While the Medication Chart and Assessment Form have noncompliance rates of 61.1% and 58.1%, respectively, with the given set of parameters. Therefore, major modifications were recommended to these forms.
Rest other medical forms have a noncompliance rate of <50% with the given set of parameters. Moreover, analysis of data revealed that existing forms are not fully rationalized with the given set of parameters of the customized checklist.
Medication chart
It is used in in-patient departments by health-care provider and consists of heads regarding patient identification and medication dosage and schedule [Figure 1]. Gap analysis was carried out through the tool kit [Figure 2], and deficiencies encountered were implemented [Figure 3].
Assessment form
It is the form used to document the information regarding the patient complaint, history of symptoms, review of systems carried out by the physician, admission diagnosis, and plan of care (Huffman, 1994) [Figure 4] Gap analysis was carried out through tool kit [Figure 5], and deficiencies encountered were implemented [Figure 6]. | Figure 4: (a) Assessment Form (Part A). (b) Assessment Form (Part B). (c) Assessment Form (Part C)
Click here to view |
 | Figure 6: (a) Rationalized Assessment Form (Part A). (b) Rationalized Assessment Form (Part B). (c) Rationalized Assessment Form (Part C)
Click here to view |
| Discussion | | |
A standard can be defined as a statement of expectation that defines the structures and processes that must be substantially in place within an organization to enhance the quality of care. In the domain of standardization of MR forms, it was observed that a few studies were conducted in this aspect, and variation was encountered in terms of different research designs, sample size, and content areas, which makes it difficult to present a direct comparison among studies.
While MR data have frequently been considered the “gold standard” data (i.e., the most complete and reliable data available for understanding the patient care process) for quality reviews, they have inherent problems that should be recognized.[6] As MRs are often poorly designed (Wyatt and Wright 1998),
The WHO stated some important points about forms in the MR: (1) Forms should all be the same size, usually A4. (2) The patient's name, MR number, and the name of the form should be in the same place on every form. (3) Only official forms approved by the administration or MR Committee (if there is one) should be included in the MR.[7]
In 2002, a study carried out in various Italian regions by the Agency for Regional Health Services showed that only 0.5% of the MRs fully satisfies the 26 quality criteria, and even in the hospital with the best performance, the indicator of acceptability stopped at the value of 6.7%. The main deficiency was represented by the traceability of signatures in the medical journal.[8]
Following major deficiencies were observed in preidentified medical form:
- Lack of standardized form name in the preidentified medical form, since it is a part of the form identification, it should be placed in one standard position
- Form number which helps the user in identification of MR form in MR folder should be present on the right side of the medical form, but noncompliance was found with the aforesaid standard in the existing MR forms, as the form number was mentioned on the left side
- A uniform logo and the name of the institute in the preidentified medical form were found to be omitted
- Variation in terms of form size was encountered in the preidentified medical form. A standard paper size should be selected by the MRs Committee.
Therefore, evidence-based modifications were needed to rationalize the preidentified MR forms in conformance with inter/national guidelines, so as to ensure structural and contextual uniformity for the prospective in-house users, and based on the baseline assessment of this study conducted, remaining MR forms among the different departments/specialties of SGPGIMS will be rationalized in a systematic phase-wise manner.
| Conclusion | | |
Quality improvement in health care means a systematic approach by a healthcare organization that monitors, assesses, and improves the standards of quality health care. This study conducted is an endeavor toward the amelioration of MR forms. Based on the observations made from the study, there was a need to rationalize MR forms by implementing the observations made from the study, so as to ensure structural and contextual uniformity as a tool for quality improvement under the domain of MR forms.
For the aforesaid measure, a proposal to update the MR forms had been sent to MRs Review and Audit Committee of SGPGIMS, and the intervention is in the process phase to update the in-use MR forms at SGPGIMS.
Recommendations
The following recommendations can be made for Quality improvement to update the MR forms with the best practices within the hospital:
- A good-quality assurance program is essential to the hospital organization for the effective functioning of MRs department
- Written policies and procedures for effective maintenance of MRs which are commensurate with the overall policies of the health-care facility should be made available to all the concerned stakeholders
- The MRs Committee should periodically review the quantitative and qualitative services rendered by the MRs through medical audits
- Periodic review by MRs Committee should include the MR format, clinical pertinence, legibility of documentation, completion, overall adequacy, the accuracy of coding, indexing of diseases and operation procedures, and collection and preparation of statistical information
- MRs Committee should progressively review and revise as necessary current MR forms and other forms to ensure that they comply with the guidelines.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | Mogli G. Medical Records Organization and Management. 2 nd ed. Jaypee Brothers Medical Publishers; 2017. |
| 3. | Mann R, Williams J. Standards in medical record keeping. Clin Med (Lond) 2003;3:329-3 2. |
| 4. | Unit HI, Connecting NH, Governance I, Authority NH, Development S, Hiu T, et al. RCP approved – Generic medical record keeping standards. Int J Sci Res 2007;M:3-4. |
| 5. | Were SM. Management of records in health institutions. Int J Sci Res 2015;4:2013-6. |
| 6. | Banks NJ. Designing medical record abstraction forms. Int J Qual Health Care 1998;10:163-7. |
| 7. | Azzolini E, Furia G, Cambieri A, Ricciardi W, Volpe M, Poscia A. Quality improvement of medical records through internal auditing: A comparative analysis. J Prev Med Hyg 2021;60:1-9. |
| 8. | World Health Organization. Medical Records Manual a Guide for Devloveping Contries. Publication of World Health Organization; 2002. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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