Letter Forms (cForms)
Letter Forms facilitate standardized documentation while accommodating a stakeholder's requirement for a particular documentation format. The forms can be rendered in a print and fax-friendly format for easy communication (In Basket, email, eFax or print). The underlying templates can take advantage of SmartTools, allowing interactive charting (e.g., click-to-edit). Double data-entry is minimized because much of required information can be pulled from the patient's chart and presented to the clinician for final editing.
Sidebar or pop-up links to Letter Forms are grouped by category, with form-specific details provided below.
Finding Letter Forms
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 "Letter Forms" link from the index; or use the link provided in the Consent & eForms Navigator) 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.
Sending Letter Forms
It is important to pay attention to the person(s) or organization(s) that the form is addressed to (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.
Absence Notes
Absence notes are simple letters often requested of healthcare providers. There are variants appropriate to caregiver, school, work and other needs for documenting a patient or family member health conflict with a pre-existing commitment. Although clinicians are free to edit or add additional information, the default absence letter is usually sufficient, as is the default recipient (patient). The content automatically adjusts to the clinical context (inpatient, outpatient, emergency). Absence letters print to a device appropriate for the patient's location.
Approval Requests
Approval requests usually relate to medications or devices that are not normally covered by patients' government or third party health insurance plan(s).
The Connect Care team is working with external stakeholders (e.g., Blue Cross) to digitize exemption and approval forms. As an interim measure, links are provided to external forms that can be completed online, then attached to the "Media" section of the Chart Review activity. This attachment process is facilitated by use of the "+Media" button under the "Attachment" section of the Communications activity. A cover letter template is provided to allow the communication to the external stakeholder to follow a Letter Form workflow.
Assessments
Medical assessments, including physical examination reports, may be required by stakeholders in a patient's health care. Assessments adapted for documentation within Connect Care are available via the pop-up and sidebar links described above.
Assessment forms tend to pull in more complex data from the patient's digital health record. Clinicians should attend to the following:
Interactive charting - Take advantage of links embedded in the form (recognized by dark-blue font colour). These allow for just-in-time review or editing of data that is pulled into the form.
Refresh - The refresh button in the toolbar at the top of the form editing window should be used after any linked data editing. This ensures that the latest data is pulled into the form.
Recipients - Recipient consideration for Letter Forms apply. However, assessments are typically send to a care team member (e.g., transition coordinator) who then forwards to one or more interested parties.
Chart Access
The Clinical Information Sharing Approach (CISA) outlines how health data is collected, accessed, used, disclosed and exchanged in the Connect Care clinical information system. While patient charts should only be accessed by clinicians in their circle of care, the CISA additionally supports information access for functions supporting patient care less directly. These include:
Promoting safe and timely patient care
System improvement
Tracking population health
Quality improvement and assurance
Research and teaching
All Connect Care patient information access is monitored for indicators of possible inappropriate access. Accordingly, those accessing information for approved secondary uses may want to document access in a way that does not clutter the patient record but still remains available to any future chart access audits.
A "chart access" form can be generated using cForms as described above. No edits are required but additional explanatory comments can be added. Addressing the letter to oneself (".ME") is recommended but the form can also be copied to a relevant health administration team or medical leader, as appropriate. The form will attach to the chart in the Chart Review "Letters" section and can be filtered for by using the "Reason for Letter" field.
A "disclosure of harm" form can also be generated under this category. The workflow is the same, facilitating Connect Care disclosure of harm best practices.
Note that consent for or documentation of chart disclosure to patients is handled through the Consent & eForms Navigator where a "Consent to Disclose Health Information" digital form can be found.
Material/Device/Assist Requests
Some Letter Forms support requests for equipment or services from stakeholder organizations. These usually demand specific details about the requested device properties or features. Letter Forms tend to pull in more complex data from the patient's digital health record. Clinicians should attend to the following:
SmartLists - Be sure to use the F2 key to work through any SmartLists that facilitate detail adjustments within the form.
Recipients - Note any instructions provided within the form respecting where to mail or fax the completed form.
Community Notifications
A simple letter form can be used to alert community health care organizations or providers to important information or updates. Managing these with a cForms workflow can help to keep a record of the communication in the chart while using appropriately secured communication channels.
Pharmacy Notifications
Community pharmacies may benefit from listings of all current medications, recent medication discontinuation instructions, or other information about relevant therapeutics or adverse reactions.
An outpatient medication community pharmacy notification is available to support outpatient care, as well as situations where inpatient care requires "external" pharmacy services.
Provider Notifications
A Primary Care Provider (PCP) notification letter alerts a patient's primary care provider that they have been identified in this role by the patient. The letter includes instructions for making corrections to the patient attachment part of the health record.
WCB Claims
Reports supporting worker compensation claims can be initiated from Letter Form links in pop-up and sidebar lists. The links open a SmartForm that facilitates appropriate data capture, and is sent automatically to WCB via Connect Care.