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1 Trust Policy and Procedure Document ref. no: PP(16)276 Form Creation Policy For use in: For use by: For use for: Document owner: Status: Trust wide All staff Management of Form Creation Health Records & IM&T Approved PURPOSE OF THIS POLICY This policy provides a robust framework for the design and implementation of patient form documents under the general title of forms. It covers the format, production, consultation process and approval of key documents. CONTENTS 1.0 Executive Summary 2.0 Document Design Standards Document Layout Standards Page Layout Standards Page Contents Standards Data Entry Recommendations 5 APPENDIX 1 7 APPENDIX 2 8 APPENDIX 3 10 APPENDIX 4 11 Author: Manager of Health Records & Outpatients Status: Approved Page 1 of 11

2 Executive Summary The Trust has a formal governance process in place to ensure that all forms (including the allocation of form titles and form codes) and form amendments are controlled via the Health Records Committee (HRC). See Appendix 1 for HRC documentation. All forms used in connection with patient care that form part of the Trust patient record will need to comply with the design principles set out by the Trust in line with Clinical Negligence Scheme for Trusts CNST. In some cases this will involve a complete re-design of a form and in others a minimal re-design to incorporate space for a form unique identifier and if not already included, a space for an addressograph label. This document should be followed when producing new Trust clinical Trust forms that form part of the Trust patient record. There is a cost implication to the design of all new forms and users should be aware that a Cost Code will need to be provided for the design work and any print costs resulting from the document. Quotations should be obtained in advance of any work being undertaken and approval sought from the budget holder for the funding of the form/document. This document should be followed when producing new Trust clinical forms that form part of the Trust patient record. 2. Document Design Standards 2.1 Introduction The following sections of this document provide an overview to the design standards which should be followed when any new forms are being designed. Please also refer to the Standard Operating Procedure: Form Creation Guidance (Appendix 2) Scanner Friendly Paper documentation filed in patient case notes is scanned into the Evolve system as a Digital image. To ensure the quality of the scanned image the following design consideration should be taken into account. Avoid the use of colour including coloured paper, highlights and background colours. Where possible design black and white forms. Typeface used Arial if this is not available then Courier can be used as a default font. Use clearly defined and segregated areas within forms with clearly delineated boundaries, particularly where hand written information is to be added to these areas. Clearly align text to any related graphics on the page Consistent placement and size of key document data items, particularly in headers and footers for example page titles, form number and page numbers. The use of print margins for the page and around key items such as headers and footers (0.8cm clear space headers and footers). Author: Manager of Health Records & Outpatients Status: Approved Page 2 of 11

3 3. Document Layout Standards 3.1 Introduction Consistent forms layout will help both in the accurate data entry and hand written completion of forms and also in their use and interpretation by clinicians. The following standards are recommended: The form name (for example Fluid Balance Chart) is printed in the top left corner on the front page of every form The Trust logo should appear in the top right corner on the front page of the form The addressograph label identifying the patient demographic, details which will include name, NHS number, hospital number, date of birth and gender. This will be need to be positioned in the top left hand patient information box marked place addressograph label within this boxed area ensuring it is placed as accurately as possible within the box space provided. A form unique identifier which would contain, E (for electronic scanning), Department/Speciality (or if Trust wide form, Ward; Theatre; Pathway; Chart, etc.) Form name, Form number, Form version, Date created and Page number. This should appear as a footer at the bottom of each page Document Colour Printing, Multipage Document Scanning and Paper Quality Where possible all forms should be black and white A4. Only where there is a specified clinical need or where there is a specific patient safety issue is colour to be used. Where a multiple page document is required, this will be designed in such a way that it can be taken apart in order to meet the evolve scanning system. The following are the recommendations around paper quality: Table 1 Paper Quality Configuration Details Weight 80gsm Thickness in. / mm (recommended 0.127mm) Smoothness mg (recommended 100) Reflectance 70% or more (recommended 90% or more) Opacity 90% or more Recommendations for margin sizes (on A4 pages) are shown below: Top of page Left edge Right edge Bottom edge 1.27cm 1.7cm (to allow for punch holes and binding) 1.27cm 1.27cm Author: Manager of Health Records & Outpatients Status: Approved Page 3 of 11

4 4. Page Layout Standards 4.1 Introduction This section of the document will provide recommended standards for the layout of pages for example page titles, page numbers etc. 4.2 Page Header The page header section should contain the following details: Table 2 Page Header Configuration Area (front page) Details Form title This should be printed on the left side of the header. The form title should provide a clear indication of the purpose. Trust Logo Printed at the top right hand side of the form. Patient demographic This addressograph label should be positioned at the start of the patient addressograph label demographic section in the form. The area should be clearly identified inside a lined box. 4.3 Page Footer The page footer section should contain the following details: Table 3 Page Footer Configuration Area (each page) Details Form Unique A form unique identifier which would contain E/Dept/Specialty/ Identifier WHS Form number, date created, version number and page number in font style Arial, Bold, in CAPS and a minimum of font size 9. This text should be at the bottom of the form: the first part - E/Dept/Spec/WSH Form number should be aligned to the left and the second part date created, version number and page number should be on the same line, but aligned to the right Separator Line A separator line (in Bold) should be included which should have the wording above the line Do Not Write Below This Line, typeset using Arial, in Bold, font size 9. This will ensure that the form Unique Identifier is the only item below the line. For scanning purposes, please allow sufficient space between the line and the form unique identifier. T he height of the page footer should be sufficient to accommodate the form unique identifier (set at 0.8cm) 4.4 Page Fonts The table below shows the main fonts and sizes that are to be used for form text. Table 4 Main Page Fonts Area Font Style and Size Page Header Form titles should be typeset using Arial, Bold and a minimum of size 14 Page Footer Page footer should be typeset in CAPS using Arial, in Bold, size 9 Form status indicator should be typeset in CAPS using Arial, in Bold, size 9 Form unique identifier should be typeset in CAPS using Arial, in Bold, font size 9; Page Text Body text should be typeset using Arial a minimum size 9 Author: Manager of Health Records & Outpatients Status: Approved Page 4 of 11

5 5. Page Contents Standards 5.1 Introduction This section of the document provides guidelines for content which appear in the main body of the form. The recommendations are split into the following sections: General page layout Data entry recommendations. 5.2 General Page Layout The table below provides examples of good practice design relating to the overall layout of individual pages Table 5 General Page Layout Page Element Design Recommendations Columns A good way to improve the usage of space on a page is to divide it into two columns. Lines Use straight lines to divide information (for example data entry areas, sections etc) within an individual section. Boxes Box off information to show emphasis or segregation within a section. 6. Data Entry Recommendations This section provides design recommendations related to the elements on each page used to allow the user to enter the relevant information onto the page. 6.1 Character Control Boxes It is recommended that where possible the use of character control boxes are used when users are entering data for specific pieces of information (for example surname, date of birth, post code etc). As most readers will start at the top of a page and work their way to the bottom in a natural reading manner it is best practice to have questions that appear one beneath each other rather than side by side. 6.2 Multiple Choice Fields In general, in order to improve recognition results, most of the questions on the form should be in Check Box format rather than alpha or numeric. The check box option text should be placed to the left of the check box and be left aligned to ensure that all of the options appear in a column to ensure that the reader can scan down and select the correct option. Where there may be some confusion as to the number of boxes to be selected the form should include a prompt informing the user how many of the options are to be selected. Author: Manager of Health Records & Outpatients Status: Approved Page 5 of 11

6 6.3 Use of Date Fields Dates should be recorded in the format DD / MM / YYYY on forms and sufficient space should be provided to allow the user to enter the information onto the form. The data entry boxes should also provide the DD / MM / YYYY prompts within the box to ensure the user understand what information is required. 6.4 Patient Demographic Naming Conventions Although the majority of patient demographic information will be included on the form as an addressograph label it is important that this information conforms to an agreed standard. Please see the table below which provides recommended naming conventions: Table 6 Patient Demographic Naming Conventions Field Name Details Patient Name The patient s name NHS No. The patient s NHS Number Hospital No Patients Hospital Number Date Of Birth The patient s date of birth Gender Tick box male or female Document Configuration Information Author(s): Health Records & Outpatients Manager. Other contributors: RMS Supervisor Approvals and endorsements: Health Records Committee Consultation: Health Records Committee Issue no: 3 File name: O:/Information Governance/Trust Policies/ Supersedes: 2 Equality Assessed Implementation To be published on the Website. Copy to all Corporate Managers. Monitoring: (give brief details how this will be done) Other relevant policies/documents & references: Additional Information: Notice in Green Sheet. A rolling program of audit and monitoring is undertaken with results tabled at Health Records and Information Governance forums. All audits are collated by the Trust Governance Department. NHS Standards for Documentation 2003; Nursing and Midwifery Standards for Record Keeping 2007; Royal College of Surgeons Standards for Documentation 2005; Worcestershire Acute Hospitals NHS Trust To be used in conjunction with Trust Health Records Policy Author: Manager of Health Records & Outpatients Status: Approved Page 6 of 11

7 APPENDIX 1 APPROVAL PROCESS FOR PRINTING PATIENT RECORD DOCUMENTATION - CHECKLIST Intranet: Trust Information/Forms/Form creation guidelines BEFORE presenting to HRC please ensure that the document complies with the Form Creation Guidelines and has been through the Evolve test scanning process. Forms/Documents failing to comply with the standards will be withdrawn. Please see Trust Intranet for a copy of Health Records Policy - Form Creation Guidelines. On completion of approval by Health Records Committee, please send a copy of HRC signed authorisation form accompanied by the document/form to Central Purchasing Unit at WSH as authorisation to proceed with your form order request. Author: Manager of Health Records & Outpatients Status: Approved Page 7 of 11

8 APPENDIX 2 Standard Operating Policy Form Creation Guidance: 1. You must ensure that your form has an appropriate and relevant title. This should be included on the top left side on the front page of the form. 2. You must attach an addressograph label at the top left side on the front page of the form (in an outlined box to ensure it is aligned correctly) beneath the form title. 3. If no addressograph label is available, you must include the following patient identifiable data on the front page of the form (within the space you would allocate for the addressograph label as in point 2 above): a. You must the patient s full name b. You must include the patient s date of birth (DD/MM/YYYY) c. You must include the patient s NHS number (3-3-4 format, e.g ) d. You must include a hospital number (CRN) 4. You must include the Trust logo on the top right hand side on the front page of the form. 5. It is preferable that the document is A4. 6. It is preferable that your document is in portrait not landscape. 7. If your document is a booklet it will need to be guillotined and separated, it is preferable that your document is on separate A4 sheets. 8. It is advisable to include a space for Consultant/Clinician, signature, name, Dept and date. 9. It may be useful to you to have colour on your document whilst you are using it for that patient episode, but if the colour is important when you retrieve it electronically you will need to discuss this with the evolve project team. Although colour has been used in paper notes for easy retrieval of your information, there will be other ways to locate your document easily within the electronic system. 10. If you are re-designing a current form, you should use the form number already provided by Central Purchasing (e.g. WSH 123) 11. If you are designing a new form, you should contact Central Purchasing to provide you with a form number (e.g. WSHI 123). 12. You will need to include the form number within the Form Unique Identifier, which should be made up as follows (see also example form in Appendix 4). This text should be typeset using Arial font size 9, in Bold and CAPS. [E][Dept][Spec]/[Title][WSH #NNNN] [Date created #DD/MM/YYYY][Version Number#v1.0][Page number#nn] E = electronic scanning Dept = department specific forms (abbreviation) Spec = specialty (if applicable) (abbreviation) Title = abbreviation for form title - if the form is not department specific and is used trust wide, the form title would be used, e.g. Drug Chart WSH NNN = form number allocated by Central Purchasing Date Created = date form is created Version number = form version number, e.g. v1.0 Author: Manager of Health Records & Outpatients Status: Approved Page 8 of 11

9 Page number = form page numbers, e.g The Form Unique Identifier should be included in the footer of each page, [E][Dept][Spec]/[Title][WSH #NNNN] should be left aligned and, on the same line, [Date created #DD/MM/YYYY][Version Number#v1.0][Page number #NN] should be right aligned. 14. You should include Do Not Write Below this Line (and insert a line), using typeset Arial font size 9, in Bold above the form unique identifier. This will ensure that the form unique identifier is the only item below the line to support correct scanning. 15. You should a copy of your draft form to the evolve forms mailbox: joanne.read@wsh.nhs.uk or becki.simpson-shaw@wsh.nhs.uk for test scanning at least 2 weeks prior to the HRC meeting. 16. Once you have drafted your form and it has been tested by the evolve project, please complete the Approval process for Printing Patient Record Documentation Checklist (see Section 2 below) and submit together with a copy of your form to the Health Records Committee at least 1 week before the HRC meeting. 17. The Health Records Committee will review the form and approve/decline as appropriate. 18. If approved you should submit your approved final copy together with a copy of HRC authorisation form to Central Purchasing Unit as authorisation to proceed with your form order request. Please also send a copy to joanne.read@wsh.nhs.uk or becki.simpsonshaw@wsh.nhs.uk 19. If you make any other changes to the final form or create a new version these must be approved by Health Records Committee, following the guidelines above. 20. If the form is not approved by HRC, you will need to make the necessary amendments, as advised by HRC, and re-submit to joanne.read@wsh.nhs.uk or becki.simpsonshaw@wsh.nhs.uk for re-testing and then HRC for approval. 21. A process map outlining the requirements listed above is available (See Section 3 Process Maps). 22. To receive further advice and guidance please the evolve forms mailbox: joanne.read@wsh.nhs.uk or becki.simpson-shaw@wsh.nhs.uk Royal College Guidelines It may also be worth noting that these state that: 1. All entries in notes should be dated and timed 2. All entries should be in black ink 3. All entries should have the name, designation and signature of those creating the note. Author: Manager of Health Records & Outpatients Status: Approved Page 9 of 11

10 APPENDIX 3 Form Creation Process Map Author: Manager of Health Records & Outpatients Status: Approved Page 10 of 11

11 APPENDIX 4 An example Form is depicted below with callouts highlighting the significant areas. Author: Manager of Health Records & Outpatients Status: Approved Page 11 of 11