Doctor Resources and Guides

10 Minimum Standards for Medical Forms

March 2015

Introduction

Red tape medical forms are an unproductive and intrusive demand upon the valuable time and resources of medical practitioners.

Patients often regard medical forms as being an inconsequential part of a more complex medical consultation. However, these red tape medical forms can place a heavy burden upon the medical practitioner who then has less time to provide essential medical care.

Organisations that produce medical forms depend heavily upon their accurate completion to determine patient entitlements. These forms usually have very serious consequences for effective service delivery and the financial efficiency of an organisation. Unfortunately these organisations frequently fail to appreciate the implications upon those vested with the responsibility of completing the forms.

Ultimately medical practitioners have a professional obligation to ensure all forms completed comply with minimum professional standards of relevance and contain the minimum amount of information for the purpose intended whilst respecting time, costs and accountability.

AMA 10 Minimum Standards for Medical Forms

In recognition of the need for greater clarity, and the fact that there is a good clinical safety reason to use standardised electronic forms specifically to reduce transcription errors, the AMA has developed the following “10 Minimum Standards for Medical Forms”. These standards are intended to instruct, guide and measure the performance of organisations that rely upon medical practitioners to assist the effective conduct of their business and programs.

Available & Accessible

1.     The form is available in an electronic format that is compatible with existing electronic general practice medical records software.

2.     Forms are distributed through medical software vendors. Access to forms does not require web surfing during consultations, nor form-filling online.

Value GP Time

3.     The form has a clear notation that states that medical practitioners may charge a reasonable fee for their services and whether the services are rebatable by Medicare or other insurers.

 Not Onerous & Respect Privacy

4.     Demographic and medical data can be selected to automatically populate the electronic form with adequate space being provided for comments.

5.     Only information essential for the purpose is requested and must not unnecessarily intrude upon patient privacy.

6.     Forms do not require the doctor to supply information when a patient can reasonably provide this in their own right.

Easy to Administer

7.     A copy is saved in the patient electronic medical file for future reference.

8.     Data file storage size is kept to a minimum.

9.     Prior to their release, forms are field tested under the auspices of a recognised medical representative organisation such as the AMA and the RACGP in association with the MSIA (Medical Software Industry Association).

10.  Consideration should be given to future compliance with encrypted electronics transmission capability in line with new technologies being introduced into general practice.

The AMA is of the view that medical forms should remain available in paper format for times when computer access is unavailable. 

The AMA is also of the view that any forms that require regular updating such as Centrelink Forms, have at the top of the Form a box which can be ticked if there has been no significant change since the last report, to indicate that the rest of the form need not be completed.

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