MEDICAL RECORD FORMS DESIGN AND DEVELOPMENT

Medical Record Forms are regularly being reviewed and new forms designed as the needs of
clinicians evolve and we learn from the ongoing examination of clinical documentation. It is
imperative that any new or existing documentation is consistent with the direction of the
organisation and adheres with medico-legal requirements. Compliance with these
guidelines ensures all clinicians can document the care and treatment they provide accurately
and succinctly.
The process for designing and implementing new Medical Record Forms at RWH is as follows:

Idea for NEW OR

Read RWH Medical
REVISED form!
Records - Design of
Consider the following BEFORE beginning the design:
forms Policy
(please complete attached proforma)

* What is the rationale for the form?

* Are there any other forms that are similar / where the same
information is collected?

* Can the form's purpose be met by using other forms / modifying

existing forms?

Discuss
Discuss proposed
proposed Form
Form with
with HIS
Julie Ritchie
department
HIM x2629
Identify Sponsor for
proposed Form
(Medical Record
Committee member)
Consider Medico-legal advice

Present DRAFT Form

to Medical Record
Committee meeting
(using proforma)

Revise Form based

on Committee
feedback

Re-present Form to
Committee

Form approved for

TRIAL in clinical area
(including
evaluation)

Form reviewed by
Sponsor and/or IMPLEMENT Ongoing evaluation of
Committee; FORM Form
Amend if required

Form reviewed by
Sponsor and/or
IMPLEMENT Ongoing evaluation of
Committee;
FORM Form
Amend if required RWHRWH Medical
Medical Record
Record Committee
Committee
January
January 20032003
MEDICAL RECORD FORMS DESIGN AND DEVELOPMENT PROFORMA
Please complete the following when proposing the development of a new Medical Record Form or
revising an existing Medical Record Form. This proforma can then be sent to a member of the Medical
Record Committee (see names below), to sponsor and present to the committee.

Department Name: Date:

Department Representative: Ext/Pager:

Forms Committee Sponsor: Ext/Pager:

Request to: (circle) a) create a new form OR b) revise an existing form

If modifying an existing form:

Form title MR number Stock item number

PART A: When proposing a new form/changes to existing form:

What is the rationale for the form / for changing the Form?

Are there any other forms that are similar / where the same information is (or could be) collected?

Can the form’s purpose be met by using other forms / modifying existing forms?

Who will use the form eg: departments / predicted quantity?

What level of consultation with users has taken place?

Who will be paying for the artwork and printing of the form?

Cost Centre: Signature of Cost Centre Manager:

RWH Medical Record Committee
January 2003
PART B:
Design of a new Form / Form revision:
Once the development of a proposed form is agreed upon, the format needs to fulfil the criteria outlined in
the “RWH Medical Record Forms Design” policy. Please check your draft form meets the following
requirements:
• Meets Australian Standard for paper based health record AS2828
• Be black print on white paper. If other colours are requested, please seek advice from Health
Information Services as all forms must be reproducible
• Have a MR strip (colour and number designated by HIS)
• Hospital name and logo (top left hand side)
• Have space for the patient ID label on the top right hand corner and on each page if pages may
be separated
• A4 size with allowance for a binding margin on the left hand side (margins 2cm on left and 1cm
top, bottom and right side)
• A reorder / stock number will on the bottom left hand corner in the binding margin including the
month and year of design
• All forms must have an area for the user to date, sign, print name and designation
• Only approved abbreviations are acceptable for use on forms
• Form name should be consistent between the top heading and border
• While being trialed, a version number of the draft should be indicated in the left hand border near
the month and year of design
• All forms must have two holes drilled in the left hand binding margin

Trialing form:
Before implementing any new form it is important to iron out any problems / minor errors by trialing the
form. The required length of the trial varies depending on how often the form will be used and how many
staff will need exposure to the form. Feedback should be received throughout the trial so that
improvements can be made to the form if required.
Implementation guide:
To enable new medical record forms to be utilised properly, ALL users need to be well informed and
educated about them. For the best effect, implementation needs to be thorough, imaginative and include
any staff who may use or refer to the form at any stage (not just those who will use it regularly).
The following implementation tools are recommended:
• Posters (bright, colourful, placed anywhere that will be seen by users)
• Notes on time cards / memos
• Provide background literature if appropriate
• Educate staff from all disciplines/departments who may use or refer to the new form
Discontinuing old Forms:
If you are replacing an existing Medical Record Form the following procedure is to be followed:
1. Contact Material Resources Department to determine:
a) how many old forms are in stock
b) what these forms cost
2. If a new form is being designed, ask Material Resources to DISCONTINUE printing of existing form
3. Old forms need to be EITHER:
a) used up before the new form is implemented OR
b) paid for by the relevant department(s)
RWH Medical Record Committee:
Jeremy Oats, Clinical Director Obs& Gynae x3302 Caroline Mulcahy, Director Neonatal Services x2659
Dianne Fletcher, Director Gynae Services x2136 Chris Bayly, Associate Director of Obstetrics and
Bobbie Carroll, Director Maternity Services x2155 Gynaecology x2829
Neil Roy, Director Neonatal Services x2335 Helen Makregiorgos, WSSS x2124
Melinda Onori-Maglitto, Manager HIS x2087 Sharyn Donovan, Clinical Service Support x2070
Jo Raw, Coordinator HIM x4964
Julie Ritchie, HIS x2629

Any of these members can sponsor a new/updated medical record form.

RWH Medical Record Committee

January 2003