Part of work underway to prepare for Children’s Hospital of Saskatchewan’s Opening Day

In preparation for the opening of Children’s Hospital of Saskatchewan (CHS), upon your next visit, you might notice something different in the way your information is put into your chart or your child’s chart.

“During the design phase for the new building, staff and physicians created care models that had them charting at the bedside through a computer. They designed the physical space and clinician workflows with the assumption they would eventually be supported by a full electronic health record. As a result, there is minimal storage space in the new facility for paper and patient charts,” explains Lori Chartier, Director with eHealth and Health Information, Saskatoon Health Region.

While a full electronic health record won’t be in place by opening day, that digital vision is now being realized step by step. A key piece of work is centralizing and standardizing the way forms are created for patient charts and other documents.

Screens showing Forms on Demand

Work is underway to implement Forms on Demand, requiring a revitalization of centralizing and standardizing the way forms are developed.

“We see multiple forms with the same information on them and variations in forms based on individual preferences,” says Suzanne Sheppard, Director Interprofessional Practice, Education and Research. “Improvements in our documentation will facilitate information flow that supports the continuity, quality, and safety of care.”

This work is led by the Clinical Health Record Forms Committee, which has existed for some time. It facilitates the development and standardization of all clinical health record forms within Saskatoon Health Region. Its mandate is to develop standards for clinical health record forms. It’s also responsible for the review, approval and inventory of all new, revised, and trial clinical health record forms that are retained on the legal health record.

“There are several drivers influencing the committee’s work,” explains Michelle McCulloch, Manager Health Records with Saskatoon Health Region, and co-chair of the committee with Sheppard. “With the coming maternal and children’s hospital, the Scanning and Forms on Demand Project is relying on updated clinical health record forms in the forms inventory. Given the limited storage space in the new CHS, it is important to ensure we can reduce inventory of clinical health record forms prior to moving into the new hospital. It’s also an opportunity for the Region to put tighter controls around trial forms in all areas and ensure changes are based on evidence and best practice.”

On May 2, 2016, a temporary pause was placed on the development and approval of new clinical health record forms until September 1, 2016. This will allow desktop publishers who work in health records the time they need to develop Forms on Demand for Children’s Hospital of Saskatchewan units that will be the first to transition to these forms.

Health Records Desktop Publisher

Health Records has a Desktop Publisher who develops forms for printing via Forms on Demand and works closely with the Clinical Health Record Forms Committee.

“Forms on Demand are the automated production of clinical forms used in the patient’s chart. Instead of drawing from a stock of paper forms, forms will be printed as required by units or departments,” explains McCulloch. “The forms will include digital patient identification from our registration system along with a required bar code and form identification to facilitate automated scanning of charts upon discharge and enabling immediate viewing of the scanned chart within Sunrise Clinical Manager.”

To support this work, the Clinical Health Record Forms Committee is revising Saskatoon Health Region Policy 7311-20-002 Clinical Health Record Form Standards, the Terms of Reference, and the Standards for Development of Clinical Health Record Forms.

“Beginning September 1, 2016, all clinicians and health care providers wishing to develop a new clinical health record form will be required to submit an application that outlines the purpose and rationale for needing the new form to the Committee,” says Sheppard. “We do not want to make changing forms difficult, but rather ensure the information flow.” Sheppard is encouraging all manager, department and division heads to ensure their staff and colleagues are aware of the changes.

“It’s important we approach this consistently as health care providers so we can begin to streamline how we develop forms and reduce the amount of paper we use. In the end, it will help all of us provide and get faster access to important patient information to assist in care delivery,” she says.

For questions on the new process and the Clinical Health Record Form Standards policy, please contact the Clinical Health Record Forms Committee Co-Chairs. Contact information can be found on the Clinical Documentation InfoNet (intranet) page.

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