03-7927. Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 88

AGENCY:

Office of Communications, GSA.

ACTION:

Guideline on automating medical standard forms.

BACKGROUND:

The Interagency Committee on Medical Records (ICMR) is aware of numerous activities using computer-generated medical forms, many of which are not mirror-like images of the genuine paper Standard/Optional form. With GSA's approval to ICMR eliminated the requirement that every electronic version of a medical Standard/Optional form be reviewed and granted an exception. The committee proposes to set required fields standards and that activities developing computer-generated versions adhere to the required fields but not necessarily to the image. The ICMR plans to review medical Standard/Optional forms which are commonly used and/or commonly computer-generated. We will identify those fields which are required, those (if any) which are optional, and the required format (if necessary). Activities may not add or delete data elements that would change the meaning of the form. This would require written approval from the ICMR. Using the process by which overprints are approved for paper Standard/Optional forms, activities may add other data entry elements to those required by the committee. With this decision, activities at the local or headquarters level should be able to develop electronic versions which meet the committee's requirements. This guideline controls the “image” or required fields but not the actual data entered into the field.

SUMMARY:

With GSA's approval, the Interagency Committee of Medical Records (ICMR) eliminated the requirement that every electronic version of a medical Standard/Optional form be reviewed and granted any exception. The following fields must appear on the electronic version of the following form:

Electronic Elements for SF 88

Item	Placement*
Report of Medical Examination	Top of form.
Standard Form 88 (Rev. 8/2001) (Form ID)	Bottom right corner of form.
Data Entry Fields:
1. Date of Exam
2. Last Name
2. First Name
2. Middle Name
3. Identification Number
4. Grade of Position
4. Component of Position
5. Home Address (Number, street or RDFD, city or town, state and ZIP code)
6. Emergency Contact (Name)
6. Emergency Contact (address)
7. Date of Birth
8. Age
9. Sex—Female (Checkbox)
9. Sex—Male (Checkbox)
10. Relationship of Contact
11. Place of Birth
12. Agency
13. Organization Unit
14a. Total Years Government Service—Military
14b. Total Years Government Service—Civilian
15. Name of Examining Facility or Examiner
15. Address of Examining Facility or Examiner
16. Rating or Specialty of Examiner
17. Purpose of Examination
18. Clinical Evaluation—Check each item in appropriate columns; enter “NE” if not evaluated	Above below listed items
a. Head, Face, Neck and Scalp—Normal (Checkbox)
a. Head, Face, Neck and Scalp—Abnormal (Checkbox)
b. Ears-General (Internal Canals) (auditory acuity under item 39)—Normal (Checkbox)
b. Ears-General (Internal Canals) (auditory acuity under item 28t)—Abnormal (Checkbox)
c. Drums (Perforations)—Normal (Checkbox)
c. Drums (Perforations)—Abnormal (Checkbox)
d. Nose—Normal (Checkbox)
d. Nose—Abnormal (Checkbox)
e. Sinuses—Normal (Checkbox)
e. Sinuses—Abnormal (Checkbox)
f. Mouth and Throat—Normal (Checkbox)
f. Mouth and Throat—Abnormal (Checkbox)
g. Eyes—General (Visual accuity and refraction under item 28li-28s)—Normal (Checkbox)
g. Eyes—General (Visual accuity and refraction under item 28li-28s)—Abnormal (Checkbox)
h. Ophtalmoscopic—Normal (Checkbox)
h. Ophtalmoscopic—Abnormal (Checkbox)
i. Pupils (Equality and reaction)—Normal (Checkbox)
i. Pupils (Equality and reaction)—Abnormal (Checkbox)
j. Ocular Motility (Associated parallel movements nystagmus)—Normal (Checkbox)
j. Ocular Motility (Associated parallel movements nystagmus)—Abnormal (Checkbox)
k. Lungs and Chest—Normal (Checkbox)
k. Lungs and Chest—Abnormal (Checkbox)
l. Heart (Thrust, size, rhythm, sounds)—Normal (Checkbox)
l. Heart (Thrust, size, rhythm, sounds)—Abnormal (Checkbox)
m. Vascular System—Normal (Checkbox)
m. Vascular System—Abnormal (Checkbox)
n. Abdomen and Viscera (Include hernia)—Normal (Checkbox)
n. Abdomen and Viscera (Include hernia)—Abnormal (Checkbox)
o. Prostate (Over 40 or clinically indicated)—Normal (Checkbox)
o. Prostate (Over 40 or clinically indicated)—Abnormal (Checkbox)
p. Testicular—Normal (Checkbox)
p. Testicular—Abnormal (Checkbox)
q. Anus and Rectum (Hemorrhoids, Fistulae) (Hemocult Results)—Normal (Checkbox)
q. Anus and Rectum (Hemorrhoids, Fistulae) (Hemocult Results)—Abnormal (Checkbox)
r. Endocrine System—Normal (Checkbox)
r. Endocrine System—Abnormal (Checkbox)
s. G-U System—Normal (Checkbox)
s. G-U System—Abnormal (Checkbox)
t. Upper Extremities (Strength, range of motion)—Normal (checkbox)
t. Upper Extremities (Strength, range of motion)—Abnormal (Checkbox)
u. Feet—Normal (Checkbox)
u. Feet—Abnormal (Checkbox)
v. Lower Extremities (Except feet) (Strength, range of motion)—Normal (Checkbox)
v. Lower Extremities (Except feet) (Strength, range of motion)—Abnormal (Checkbox)
w. Spine, Other Musculoskeletal—Normal (Checkbox)
w. Spine, Other Musculoskeletal—Abnormal (Checkbox)
x. Identifying Body Marks, scars, Tattoos (Explain in Notes)—Normal (Checkbox)
x. Identifying Body Marks, scars, Tattoos (Explain in Notes)—Abnormal (Checkbox)
y. Skin, Lymphatics—Normal (Checkbox)
y. Skin, Lymphatics—Abnormal (Checkbox)
z. Neurologic (Equilibrium tests under item 28t)—Normal (Checkbox)
z. Neurologic (Equilibrium tests under item 28t)—Abnormal (Checkbox)
aa. Psychiatric (Specify any personality deviation)—Normal (Checkbox)
aa. Psychiatric (Specify any personality deviation)—Abnormal (Checkbox)
bb. Breasts—Normal (Checkbox)
bb. Breasts—Abnormal (Checkbox)
cc. Pelvic (Females only)—Normal (Checkbox)
cc. Pelvic (Females only)—Abnormal (Checkbox)
19. Notes (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 29 and use additional sheets if necessary)
20. Dental—Acceptable (Checkbox)
20. Dental—Not Acceptable (Checkbox)
20. Dental—Not Acceptable (if checked, explain)
20. Dental—Dental Examination not done by Dental Officer
21. Remarks and Additional Dental Defects and Diseases
22. Test Results (Copies of results are preferred as attachments)	Above below listed items.
22a. Urinalysis—Specific Gravity
22a. Urine Albumin
22a. Urine Sugar
22b. Syphilis Serology (Specify test used and results)
22c. EKG
22d. Blood Type and RH Factor
22e. Chest X-Ray or PPD (Place, date, film number and result)
22f. Other Tests
23. Relationship to Sponsor
24a. Sponsor's Name—Last
24b. Sponsor's Name—First
24c. Sponsor's Name—MI
24c. Sponsor's ID Number (SSN or Other)
25. Depart./Service
26. Hospital or Medical Facility
27. Records Maintained At
Last Name—First Name—Middle Name	Top of back page.
Identification Number	Top of back page.
Number of Sheets Attached	Top of back page.
28. Measurements and Other Findings	Above below listed items.
28a. Height
28b. Weight
28c. Color Hair
28d. Color Eyes
28e. Build—Slender (Checkbox)
28e. Build—Medium (Checkbox)
28e. Build—Heavy (Checkbox)
28e. Build—Obese (Checkbox)
28f. Temperature
28g(1). Blood Pressure (Arm at heart level)—Sitting—Sys.
28g(1). Blood Pressure (Arm at heart level)—Sitting—Dias.
28g(2). Blood Pressure (Arm at heart level)—Recumbent—Sys.
28g(2). Blood Pressure (Arm at heart level)—Recumbent—Dias.
28g(3). Blood Pressure (Arm at heart level)—Standing (5 minutes)—Sys.
28g(3). Blood Pressure (Arm at heart level)—Standing (5 minutes)—Dias.
28h(1). Pulse (Arm at heart level)—Sitting
28h(2). Pulse (Arm at heart level)—Recumbent
28h(3). Pulse (Arm at heart level)—Standing—3 minutes
28h(4). Pulse (Arm at heart level)—After Exercise
28h(5). Pulse (Arm at heart level)—2 minutes after exercise
28i(1). Distant Vision—Right 20/ (number)
28i(1). Distant Vision—Right—Corrected to 20/ (number)
28i(2). Distant Vision—Left 20/ (number)
28i(2). Distant Vision—Left Corrected to 20/ (number)
28j(1). Refraction—Right—By
28j(1). Refraction—Right—S
28j(1). Refraction—Right—CX
28j(2). Refraction—Left—By
28j(2). Refraction—Left—S
28j(2). Refraction—Left—CX
28k(1). Near Vision—Right (Number)
28k(1). Near Vision—Right—Corrected To (Number)
28k(1). Near Vision—Right—By (Number)
28k(2). Near Vision—Left (Number)
28k(2). Near Vision—Left—Corrected To (Number)
28k(2). Near Vision—Left—By (Number)
28l(1). Heterophoria (Specify Distance)—ESO
28l(2). Heterophoria (Specify Distance)—EXO
28l(3). Heterophoria (Specify Distance)—RH
28l(4). Heterophoria (Specify Distance)—LH
28l(5). Heterophoria (Specify Distance)—Prism Division
28l(6). Heterophoria (Specify Distance)—Prism Conv. Ct.
28l(7). Heterophoria (Specify Distance)—PC
28l(8). Heterophoria (Specify Distance)—PD
28m(1). Accommodation—Right
28m(2). Accommodation—Left
28n(1). Field of Vision—Right
28n(2). Field of Vision—Left
28o. Color Vision (Test used and result)
28p. Night Vision (Test used and result)
28q(1). Depth Perception (Test used and score)—Uncorrected
28q(2). Depth Perception (Test used and score)—Corrected
28r. Red Lens Test
28s(1). Intraocular Tension—Right
28s(2). Intraocular Tension—Left
28t. Audiometer—Right Ear—500-512
28t. Audiometer—Right Ear—1000-1024
28t. Audiometer—Right Ear—2000-2048
28t. Audiometer—Right Ear—3000-3096
28t. Audiometer—Right Ear—4000-4096
28t. Audiometer—Right Ear—6000-6144
28t. Audiometer—Left Ear—500-512
28t. Audiometer—Left Ear—100-1024
28t. Audiometer—Left Ear—2000-2048
28t. Audiometer—Left Ear—3000-3096
28t. Audiometer—Left Ear—4000-4096
28t. Audiometer—Left Ear—6000-6144
28u. Psychological and Psychomotor (Tests used and score)
29. Notes (Continued) and Significant or Interval History
30. Summary of Defects and Diagnoses (List diagnoses with item numbers)
31. Recommendations—Further Specialist Examinations Indicated (Specify)
32. Physical Profile—P
32. Physical Profile—U
32. Physical Profile—L
32. Physical Profile—H
32. Physical Profile—E
32. Physical Profile—S
33. Examinee—Is Qualified for (Checkbox)
33. Examinee—Is Qualified for Explanation
33. Examinee—Is Not Qualified for (Checkbox)
33. Examinee—Is Not Qualified for Explanation
34. Physical Category—A
34. Physical Category—B
34. Physical Category—C
34. Physical Category—E
35. If Not Qualified, List Disqualifying Defects by Item Number
36. Typed or Printed Name of Physician
36. Signature of Physician
37. Typed or Printed Name of Physician
37. Signature of Physician
38. Typed or Printed Name of Dentist or Physician (Indicate which)
38. Signature of Dentist or Physician
39. Typed or Printed Name of Reviewing Officer or Approving Authority
39. Signature of Reviewing Officer or Approving Authority
*If no specific placement, data element may be in any order.

FOR FURTHER INFORMATION CONTACT:

CDR Katherine Ciacco Palatianos, Indian Health Service, Department of Health and Human Services, Rockville, MD 20857 or e-mail at [e-mail].

Dated: March 21, 2003.

Katherine Ciacco Palatianos,

Chairperson, Interagency Committee on Medical Records.