So what does it mean? – part 3 – forms

In this part of the “so what does it all mean?” series, I’m moving on from specific records to agreed forms designed to be filled in to become part of a person’s record. Part 1 of this series looked at the Lloyd George record folder for general practice. In part 2, I looked at the specific records of Harry Haines and Alice Capell, patients at Great Ormond Street Hospital in the 19th century.

The GP record and the historical hospital record are designed to allow a practitioner to keep a record of the care they gave. In the case of the two children’s records this was evident by the single person’s handwriting. Importantly, they are not designed to facilitate continuity of care across different people. One flaw of the GP folder was they became increasingly impractical as hospitals became more relevant to a patient’s care. The folder size did not easily fit the letters sent to and from hospitals and laboratory reports could easily become lost.

Since the GP records were designed in 1911, the interaction with other parts of the health and care system have become significantly greater as the services that could be provided have increased. In the time of Harry Haines and Alice Capell, having access to a hospital was rare and expensive. Alice was lucky to have a specialist children’s hospital across the road from her comfortable house. One approach to making the interactions between GPs and the rest of the health care market is the use of structured forms.

For the rest of this part of the series I will look at just one form and highlight some of the features and challenges understanding what it all means. I’ve chosen the ReSPECT form promoted by the resuscitation council. My choice is motivated by their preparation of the graphic below, showing the broad structure of the the form rather than the detail.

In this form, as in many forms used in the health and care sector or indeed many other areas of commerce, is designed to gather key information to support a specific business process (managing preferences towards the end of life) for a specific person. The form is designed to be held by the person and shared with health and care professionals if the person looses mental capacity. Unlike the care records looked at in parts 1 and 2 of this series, the form is completed during a conversation with the person whose preferences are being recorded rather than being simply an aide memoire for the practitioners.

Structure

As with the GP record and the Great Ormond Street Hospital case notes, the ReSPECT form starts with identifying the patient. It then has a series of sections dealing with specific topics. These start with information about the patient and the patient’s preferences. The form then moves to clinical recommendations for emergency care and a record of the assessment of assessment of mental capacity. Finally, the form includes contact details for use in an emergency and a review history.

A well designed form can assist everyone involved in care by:

• Acting as a prompt to cover all the appropriate parts of the business process being recorded. The prompts on the ReSPECT form are either in the form of questions or instructions;
• Allowing the reader to find relevant information quickly through headings describing the various sections, and
• Providing pre-canned phrases which can be selected by the author to speed up record keeping. In the case of the ReSPECT form, this is through tick boxes.

The ReSPECT form also includes identifiers for the patient (NHS number, Scottish Community Health Index number or Northern Irish Health and Care number) and the clinicians completing the form (their professional registration number).

This form mixes the recording of information and the process to record that information in a consistent way. The headings are prominent, allowing the reader or form author to quickly find the right section. In the first section we have a yes/no question – does the person have capacity. The process then includes some “skip logic” so that if the answer is “No” an additional question needs to be answered. The process is also clearly explained to the person completing the form.

In the next section there is again a tick-box answer set but this time three statements to choose from. The third option again has a supplementary question to answer if it is chosen. The context of option C is refined by the choices 1, 2 or 3 that follow. While choices 1 and 2 are mutually exclusive, tick-box 3 could apply whether or not the child has mental capacity. Finally, there is an option D to provide a textual description of the person’s circumstances.

The next three sections include repeating groups for the clinician’s details (and a signature to “attest” the information recorded), the contact details of people to contact in an emergency and review details.

In that small section of a form a complex set of facts can be represented. Understanding the filled in form needs an understanding of the blank form and the choices it offers. “What does it all mean?” is more complex to work out than in the simple linear journals of the GP record or the historical hospital records, yet the form makes this clear to the reader.

Role in continuity of care

Patient held forms and booklets have been the dominant way of enabling care to be coordinated across different parts of the health and care system. They are particularly useful where a known process spans multiple professions, organisations and locations. The maternity “cooperation” card or child health “red book” are a couple of other examples most people will have come across.

The ReSPECT form also enables continuity of care in an emergency by providing people with a summary of the key details about the person’s health and the care they are receiving. Summarising health and care is an essential part of the health and care process. It allows the reader to quickly gather the information they need when time is short, such as in urgent or emergency situations.

In the next parts of this series I will move from the paper representations to the electronic, some of the resources available to help record keeping and explore the challenges of interpreting electronic care records.