Medical form

A combination medical form includes a Physician's Orders Sheet, a Medication Administration Record and a Treatment Administration Record. The Medication Administration Record and the Treatment Administration Record feature non-overlapping columns of instruction blocks and a series of columns of record cells arranged in a space efficient manner.

BACKGROUND OF THE INVENTION 
This invention relates to multiple medical forms and more particularly to 
medical forms which are especially useful in nursing homes and the like. 
Heretofore it has been customary to provide three separate forms for 
administering medical care to a nursing home patient. One of these forms 
has been a Physician's Orders Sheet for recordal of physician's orders. 
Secondly, there has been a Medication Administration Record upon which 
nurses have recorded the administration of prescribed medications together 
with notes of observations made in connection with the administration of 
the medication. The third form has been a Treatment Administration Record 
used by nurses to record the administration of prescribed treatments and 
to record observations relating to those treatments. 
Recently combination forms have been introduced which combine a Physician's 
Orders Sheet with a Medication Administration Record. These combination 
forms employ patterned carbon paper transfer sheets or patterned 
carbonless copy sheets for transferring medication instructions from the 
Physician's Orders Sheet to the Medication Administration Record. The 
carbon patterns on the transfer sheets are arranged in such a manner as to 
prevent the transfer of markings onto the Medication Administration 
Record. 
Somewhat more recently, combination forms have been introduced which 
combine the functions of all of the above three mentioned forms. However, 
these combination forms have been oversized and awkward to use due to 
conflicting demands for the same space on the form. Thus, there has been a 
need for an improved multiple part medical form which combines a 
Physician's Orders Sheet, a Medication Administration Record and a 
Treatment Administration Record in a convenient space-efficient manner. 
SUMMARY OF THE INVENTION 
This invention provides an improved multiple part medical form which 
combines a Physician's Orders Sheet, a Medication Administration Record 
and a Treatment Administration Record suitable for production in 
conventional loose-leaf notebook size. Patterned pressure-sensitive 
transfer means are employed to transfer physician's orders from a 
Physician's Orders Sheet to selective areas on a Medication Administration 
Record and a Treatment Administration Record. Customarily, administration 
records of both of the above types require a series of side-by-side cells 
arranged in vertical columns; one column for each calendar month. Space 
efficiency has been achieved by arranging the columns of administration 
record cells to flank the physician's instruction blocks on one of the two 
administration records. On the other administration record the physician's 
instruction blocks are positioned in the customary manner at the left-hand 
side of the form. For each form, however, the column of instruction blocks 
and the associated columns of record cells have an aggregate width which 
extends substantially the full width of the front face of the 
administration record form. 
In the preferred embodiment, the columns of record cells in the Medication 
Administration Record remain contiguous, while the columns of record cells 
on the Treatment Administration Record are split into bi-monthly groups 
flanking a medially positioned column of treatment instruction blocks. The 
rear faces of the Medication Administration Record and the Treatment 
Administration Record are printed to display a plurality of conventional 
data entry lines and instructions for recording administration notes on 
those lines.

DESCRIPTION OF THE PREFERRED EMBODIMENT 
A multiple part form 10 in accordance with the present invention is 
illustrated in FIG. 1 as comprising five overlaid sheets. The five sheets 
are printed and assembled in the conventional manner on a forms press. The 
forms may be produced in a continuous strip or as snap sets, marginally 
bound at the sides with vertically extending perforations 22,24. During 
use the form may be gripped alternatively at the top margin 11 or at the 
left side margin 13, as taught in Hanauer U.S. Pat. No. 5,102,371. If the 
form is gripped at the side margin 13, then it must be broken apart at the 
perforation line 24 prior to use. If it is gripped in the top marginal 
area 11, then it is broken apart at both of perforation lines 22 and 24. 
The topmost sheet of form 10 is a Physician's Orders Sheet 12 upon which a 
physician makes typed, handwritten or computer printed entry of a medical 
plan of treatment. The plan includes medication instructions which are 
entered into a vertically arranged column of medication instruction blocks 
26 and treatment instructions which are arranged into a vertically 
arranged column of treatment instruction blocks 28. Blocks 28 are arranged 
in horizontal alignment with blocks 26. Physician's Orders Sheet 12 also 
has an area 25 reserved for "other orders". The attending physician may 
write the above instructions on sheet 12 using a hard writing instrument, 
such as a ballpoint pen. The rear face of sheet 12 is entirely coated with 
pressure-sensitive microcapsules of the conventional type which rupture to 
produce a reactive dye upon being crushed by the force of the writing 
instrument. 
Immediately below sheet 12 is a duplicate copy thereof denoted by the 
reference numeral 14 on FIG. 1. The front face of sheet 14 is covered with 
pressure-sensitive microcapsules containing a dye which is reactive with 
the dye carried by the microcapsules on the rear side of sheet 12. Thus, 
all of the physician's instructions written on sheet 12 are reproduced on 
sheet 14, thereby producing a conventional "carbonless copy". The front 
face of sheet 14 is preprinted with the same information as the front face 
of sheet 12. Thus it includes a vertically extending column of medication 
instruction blocks 27 and a vertically extending column of treatment 
instruction blocks 29 (FIG. 4). Blocks 27 and 29 are in registration with 
blocks 26 and 28 respectively of sheet 12. 
The rear face of sheet 14 is coated with a pattern of pressure-sensitive 
microcapsules as generally illustrated by reference numeral 38 of FIG. 4. 
This pattern includes the lower area of the sheet which carries items such 
as the physician's name, patient's name, and other routine information. 
The pattern 38 also extends behind the row of medication instruction 
blocks 27. 
A Medication Administration Record 16 is positioned immediately below sheet 
14. The front face 41 (FIG. 2) of Medication Administration Record 16 is 
coated with a pattern of pressure-sensitive microcapsules (not 
illustrated) matching the pattern 38 of sheet 14. Again, the two types of 
capsules are reactive, so that markings within the area 38 of sheet 14 are 
transferred to the front face of Medication Administration Record 16. For 
receiving these markings, Medication Administration Record 16 has a series 
of medication instruction blocks 34 arranged in a vertically extending 
column in registration with the like-named blocks 26,27 of sheets 12,14. 
One of the blocks 34 is illustrated in detail in FIG. 2. 
The printed area of front face 41 has a width W which extends substantially 
the full width of the face. The column of medication instruction blocks 34 
has a width A, leaving a width B which is filled by a series of columns of 
medication record cells 30, one column for each day of a calendar month. 
Medication record cells 30 have a width X, so that B equals 31 * X. The 
above-mentioned pattern of microcapsules does not permit the transfer of 
any markings into the area B. That reserves the area for data entries by 
the staff nurse. 
The rear face 42 of Medication Administration Record 16 may appear as 
generally illustrated in FIG. 6. Rear face 42 is printed to display a 
plurality of data entry lines 52 and instructions 54 for recording 
medication administration notes on those data lines. Preferably, those 
instructions are printed reversibly at the top and bottom of rear face 42 
to accommodate alternative side or top binding, as discussed above. 
Reference is made to U.S. Pat. No. 5,102,371 for further details. 
The rear face 42 of Medication Administration Record 16 is in face-to-face 
contact with the front face a transfer sheet 18 as illustrated in FIG. 5. 
There is no pressure transfer material between these two faces. However, 
the rear face of transfer sheet 18 is coated with a pattern of 
pressure-sensitive microcapsules within an area as denoted generally by 
the reference numeral 40. The area 40 has an upper portion 49 which is in 
registration with the columns of treatment instruction blocks 28 of sheet 
12 and 29 of sheet 14. The area 49 is in face-to-face contact with a 
similarly shaped pattern of microcapsules (not illustrated) on the front 
face 51 (FIG. 3) of an underlying Treatment Administration Record 20. This 
permits pressure induced transfer of markings from treatment instruction 
blocks 28, 29 of sheets 12,14 into a vertically extending column of 
treatment instruction blocks 36 on the front face of record 20. Due to the 
pattern shape of the microcapsules on the front face of Medication 
Administration Record 16, the treatment instructions in blocks 28,29 pass 
marklessly through the record 16 and markingly into blocks 36. 
As shown in FIG. 3, the front face 51 of Treatment Administration Record 20 
is printed across an area of width W. It will be noted that this width is 
the same as the width of the printed area of front face 41 of Medication 
Administration Record 16. However, treatment instruction blocks 36 are 
printed medially of their associated administration record and are flanked 
both left and right by columns of treatment record cells 32 arranged to 
define a left bank 46 of width B.sub.1 and a right bank 48 of width 
B.sub.2. Treatment record cells 32 have a width X matching the width X of 
medication record cells 30. Preferably there are 31 columns of treatment 
record cells 32 so, they have an aggregate width B. 
Treatment instruction blocks 36 have a width A which is the same as the 
width of medication instruction blocks 34. Therefore the column of 
instruction blocks 36 and the columns of record cells 32 have an aggregate 
width which extends substantially the full width of front face 51 of the 
Treatment Administration Record 80. By thusly splitting the columns of 
cells 32, the invention makes it possible to assemble the record 20 in 
registration below the record 16 without loss of space on the front face 
of either record. 
It is apparent that the arrangement of the information on records 16 and 20 
could be interchanged, so that Treatment Administration Record 20 would 
appear as generally illustrated in FIG. 2, and Medication Administration 
Record 16 would appear as generally illustrated in FIG. 3. However, the 
above-described arrangement is preferred, because the relatively more 
frequent medication data entries can take advantage of the convenience of 
full month left-to-right reading. In either event the column of medication 
instruction blocks and the column of treatment instruction blocks are 
placed in non-overlapping areas of the form, and the columns of record 
cells are horizontally placed to occupy areas which are non-occupied by 
their associated instruction blocks. 
The rear face 44 of Treatment Administration Record 20 is illustrated 
generally in FIG. 7. The face 44 is printed to display a plurality of data 
entry lines 56 and instructions 58 for recording treatment administration 
notes thereon. Again, the instructions are reversibly printed at the top 
and bottom in accordance with U.S. Pat. No. 5,102,371. 
While the products herein described constitute a preferred embodiment of 
the invention, it is to be understood that the invention is not limited to 
these precise products, and that changes may be made therein without 
departing from the scope of the invention which is defined in the appended 
claims.