Forms Documentation
Clinicians often complete standardized forms when providing information to internal or external groups in support of a specific request or task. The formatted information may be provided directly to patients (e.g., print or portal share of a work or school absence note), attached to the chart (e.g., cognitive assessments) and/or sent to internal or external healthcare stakeholders (e.g., request for drug insurance coverage, medical assessment for long-term care).
Historically, standardized forms were optimized for printing and paper-based distribution. Many forms remain in this format, existing in file cabinets where clinicians must find them (or print from an online source), fill-in by hand, then scan and attach to the Connect Care chart. Increasingly, Connect Care provides in-system supports that can largely pre-populate common forms, then route the completed form by eFax, print or in-basket to stakeholders. This section outlines workflows that facilitate forms management.
External Forms
There remain many forms, especially those required by organizations other than AHS, that must be completed outside of Connect Care workflows (e.g., online fillable forms or printed paper forms). Death Certificates are a common example.
Working with external forms is largely a manual process, as the forms cannot interface with Connect Care. Clinicians do double data-entry and must take care to copy patient identifiers and other data faithfully. Once complete, the forms are scanned and attached to the patient chart where they can be found through the Chart Review activity within the "Media" tab.
Internal Forms
Connect Care in-system forms workflows address at least three use cases:
Set-Format - eForms
Some forms required require an organization's exact layout (including things like headers, logos and footers) to be followed precisely. The format expectation is expressed through a PDF (Portable Document Format) template that allows input to defined locations. The resulting structured document is usually attached to the Connect Care chart as a note type viewable in Chart Review ("Notes" tab), where it is available for on-demand routing or printing.
Fixed format forms are supported in Connect Care as "eForms". These generate PDF output and, to a limited degree, automatically fill fields with information from the Connect Care health record. eForms also support e-signature protocols (generated with touchpads and other tools). Examples include procedure consents and Mental Health Act forms. eForms are accessed through the Consent & eForms Navigator, linked from a menu item within the Storyboard that appears as the leftmost column of all opened charts.
Set-Content - Letter cForms
Other clinical forms require precisely defined content but the recipient organization will accept formatting that approximates but does not replicate the original paper form. These "Letter Forms" need to be rendered in a way that will handle faxing or printing, including such features as headers, footers, pagination, confidentiality notices and patient identifiers appearing on all pages. Copies of completed forms need to be kept within the Connect Care health record. Typically, letter forms are sent to stakeholders (e.g., pharmacy, Blue Cross, WCB) using a communications workflow (In Basket, eFax, email, print mail, etc.).
Set-content forms with these functional requirements are supported in Connect Care as "Letter Form" templates. These have the needed header, footer and page control elements, and are optimized for communications. In addition, they take advantage of SmartTools to automatically incorporate patient chart content, while dramatically easing data entry for clinicians. They are automatically attached to the patient chart, found in the "Letters" tab of Chart Review.
Set-Content - Note Forms
Some forms are designed to ensure that clinicians capture specific information in a specific order; however, the resulting documentation does not need to be externally communicated. Connect Care SmartTools (SmartText, SmartPhrases, etc.) enable production of progress notes, exceptional care plans and other documentation appearing within the "Notes" tab of Chart Review. These can be routed on-demand should the need arise.
eForms
Internal forms requiring a fixed format ("set-format", as above) are found within any opened chart within the Consent & eForms Navigator, found as a link within the chart Storyboard (leftmost column, just below "Other Systems"), or via the Inpatient Sidebar Form Letters display ("eForms" link), or via Chart Search (use "eForms" as keyword and jump to "Consent & eForms").
Currently, eForms are used for patient care and procedure consents and Mental Health Act forms. Other forms requiring e-signature will be added.
Letter Forms (cForms)
Letter Forms facilitate standardized documentation that aligns with a particular organization's information presentation requirements (e.g., Long Term Care Medical Assessment Form). "cForm" workflows make use of the "Communications" activity to generate print and fax-friendly outputs for easy communication (In Basket, email, eFax or print). The underlying templates take advantage of SmartTools, allowing interactive charting (e.g., click-to-edit). Double data-entry is minimized because required information can be pulled from the patient's chart and then presented to the clinician for final editing.
The Communications activity (chart search "communications" or select from chart activity menu) provides access to most letter form functions. However, sidebar tools (chart search and jump to "Prescriber Sidebar", then select the link for "Letter Forms") provide a more seamless experience by allowing clinicians to simply click on a link for the form they desire. This automatically sets up the correct form, with the correct properties, ready for editing in the Communications activity.
The experience of working with a Letter Form is much like editing any other note in Connect Care. In addition, it is important to pay attention to the person(s) or organization(s) that the form is addressed to. Selecting the "Send Now" button will route the form, while use of the "Pend" button will store the form without routing to a recipient. Letter Forms can be used for documentation without sending as a communication by limiting the recipient(s) to oneself. Completed forms are found in the "Letters" tab of chart review.