Documentation and record keeping is one of the pillars of any office, clinic or organization. Speaking of the hospitals and even clinics at a small scale, documentation is given utmost importance to meet the needs of a quality health care system.
Medical records or medical record forms are a part of the very chain and are considered as the most important part of a hospital management system. Medical records are maintained in hundreds of ways and serve even more purposes than we can imagine.
Why medical forms are important?
Speaking of medicinal forms and their extensive use in the hospitals and health care systems all over the world, it is good to shortlist some of the most important reasons for the immense need of medical forms.
- Medical forms are the best source of keeping and maintaining the record about patients and the management provided to them.
- They can be used for prospective and retrospective references and the management and record can be used as a reference for research purposes but of course, after the consent of the patients and their relatives in special circumstances.
- These medical records can be used for checking whether a specific management plan is successful for the treatment of the disease or not.
- Medical record forms are also used for medico-legal purposes whenever required in special situations again.
- They are used as a source of audit and a wide number of discrepancies and ideas of improvement can be picked out to improve the quality of hospital management and patient care.
- The most important reason is that according to JCIA standards, we are bound to keep the records for quick patient care in subsequent visits of these patients.
Types of medical forms
There are hundreds of medical forms which are used in a hospital set up. A good hospital has medical forms for each and every step of patient care. These forms include patient registration forms to the patient’s discharge summary and everything in between. It will not be an exaggeration if we say that there are uncountable number and types of medical forms which are being used at different levels of hospital management systems.
Medical forms begin with the patient registration in which first-time patients are registered, and their basic information is noted down as record in the hospital. After that, the patient may have to visit in an outpatient or inpatient for the purpose of medical history form which is filled at the time of admission and is updated at every visit.
Some forms are used as consent forms in which patients have to sign a consent for a particular surgery or procedure on them. Then there are medical release forms which are duly signed by the patient to allow the disclosure of his personal and medical details for specific situations.
Whatever the type of these medical forms is, each and every medical form carried importance and it must be filled properly by the concerned persons especially the health professionals.
Medical history forms
Medical release forms
Official medical leters