97-13089. Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 558
[Federal Register Volume 62, Number 97 (Tuesday, May 20, 1997)]
[Notices]
[Pages 27608-27611]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-13089]
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GENERAL SERVICES ADMINISTRATION
Interagency Committee for Medical Records (ICMR); Automation of
Medical Standard Form 558
AGENCY: General Services Administration.
ACTION: Guideline on automating medical standard forms.
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Background
The Interagency Committee on Medical Records (ICMR) are aware of
numerous activities using computer-generated medical forms, many of
which are not mirror images of the genuine paper Standard Form. With
GSA's approval the 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 data standards and
require that activities developing computer-generated versions adhere
to the required data elements 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 data
elements which are required, those (if any) which are optional, and the
required format (if necessary). Activities may not add 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 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.
Summary
With GSA's approval, the Interagency Committee on Medical Records
(ICMR) eliminated the requirement that every electronic version of a
medical Standard/Optional form be reviewed and granted an exception.
The following data elements must appear on the electronic version of
the following form:
Electronic Elements for SF 558
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Item Placement*
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Text:
Title:
Emergency Care and Treatment (Patient)...... Top of form 1.
Emergency Care and Treatment (Doctor)....... Top of form 2.
Form ID: Standard Form 558 (Rev. 9-96).......... Bottom right corner of form.
I have received and understand these Right above patient's signature.
instructions.
Data Entry Fields:
[[Page 27609]]
These fields belong on the patient copy of the
SF 558:
Log Number
Treatment Facility
Records Maintained At
Patient's Home Address or Duty Station
(Must include Street Address, City,
State, and ZIP Code)
Arrival Date
Arrival Time
Transportation to Facility
Sex
Age
Home Phone (Include area code and phone
number)
Duty/Local Phone (Include area code and
phone number)
Military Status--PRP Yes................... DOD forms only.
Military Status--PRP No.................... DOD forms only.
Military Status--PRP NA.................... DOD forms only.
Military Status--Flying Status Yes......... DOD forms only.
Military Status--Flying Status No.......... DOD forms only.
Military Status--Flying Status NA.......... DOD forms only.
Medical History Obtained From:
Third Party Insurance--Additional Yes
Third Party Insurance--Additional No
Third Party Insurance--DD 2568 in chart DOD forms only.
Yes.
Third Party Insurance--DD 2568 in chart DOD forms only.
No.
Name of Insurance Company
Current Medications
Allergies
Injury or Occupational Illness--Is this
an injury Yes
Injury or Occupational Illness--Is this
an injury No
Injury or Occupational Illness--When
(date)
Injury or Occupational Illness--Where
Injury or Occupational Illness--How
Injury or Occupational Illness--Injury/
Safety forms Yes
Injury or Occupational Illness--Injury/
Safety forms No
Emergency Room Visit--Date last visit
Emergency Room Visit--24 hour return
Yes
Emergency Room Visit--24 hour return No
Tetanus--Dated last shot
Tetanus--Completed initial series Yes
Tetanus--Completed initial series No
Chief complaint
Category of Treatment--Emergent
Category of Treatment--Urgent
Category of Treatment--Non-Urgent
Category of Treatment--Time
Category of Treatment--Initials
Vital Signs--Time (Allow for at least
five entries)
Vital Signs--BP (Allow for at least five
entries)
Vital Signs--Pulse (Allow for at least
five entries)
Vital Signs--Resp (Allow for at least
five entries)
Vital Signs--Temp (Allow for at least
five entries)
Lab Orders--CBC/DIFF
Lab Orders--Urine C&S
Lab Orders--Blood C&S X
Lab Orders--ABG
Lab Orders--UA MSCC/CATH
Lab Orders--PT/PTT
Lab Orders--BHCC/Urine/Blood/Quant
Lab Orders--Chem
Lab Orders--(5 blank fields)
X-Ray Orders--CXR PA & LAT/Portable
X-Ray Orders--Acute Abdomen
X-Ray Orders--Sinus
X-Ray Orders--Ankle R/L
X-Ray Orders--C-Spine
X-Ray Orders--LS Spine
X-Ray Orders--Head CT
X-Ray Orders--(Allow for at least 3
blank fields)
Orders--Pulse OX
Orders--Monitor
Orders--ECG
Orders--Time (Allow for at least 4
entries)
[[Page 27610]]
Orders--Orders (Allow for at least 4
entries)
Orders--By (Allow for at least 4
entries)
Orders--Completed By (Allow for at least
4 entries)
Orders--Time (Allow for at least 4
entries)
Orders--Patient's Response (Allow for at
least 4 entries)
Disposition--Home
Disposition--Full Duty
Disposition Quarters/Off Duty--24 Hrs.
Disposition Quarters/Off Duty--48 Hrs.
Disposition Quarters/Off Duty--78 Hrs.
Modified Duty Until (Date)
Return to Duty (Date)
Patient/Discharge Instructions
Condition Upon Release--Improved
Condition Upon Release--Deteriorated
Condition Upon Release--Unchanged
Admit to Unit/Service (Date)
Time of Release
Referred To
Referred When
Patient's Signature
Patient's Name (last, first, middle).... Bottom left corner of form.
Patient's ID No. or SSN
Hospotal or medical facility
These fields belong on the doctor's copy of the
SF 558:
Time Seen By Provider
CBC--WBC
CBC--H/H
CBC--PLT
SMAC
PT
APTT
BHCG
ETOH
GLU
ABG/Pulse OX--Sup 02
ABG/Pulse OX--PH
ABG/Pulse OX--PO2
ABG/Pulse OX--PCO2
ABG/Pulse OX--SAT
ABG/Pulse OX--Other
U/A--DIP
U/A--Micro
Radiology--check if ready by radiologist
Results
EKG Interpretation
Provider History/Physical
Consult With (Allow at least 5 entries)
Time (Allow at least 5 entries)
Action (Allow at least 5 entries)
Diagnosis
Resident/Medical Student Signature
Resident/Medical Student Stamp
Provider Signature
Provider Stamp
Codes
Patient's Name (last, first, middle)........ Bottom left corner of form.
Patient's ID No. or SSN
Hospital or Medical Facility
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* If no placement indicated, items can appear anywhere on the form.
[[Page 27611]]
for further information contact: CDR Patricia Buss, MC, USN; (202) 762-
3131.
Dated: May 13, 1997.
CDR Patricia Buss, MC, USN,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 97-13089 Filed 5-19-97; 8:45 am]
BILLING CODE 6820-34-M
Document Information
- Published:
- 05/20/1997
- Department:
- General Services Administration
- Entry Type:
- Notice
- Action:
- Guideline on automating medical standard forms.
- Document Number:
- 97-13089
- Pages:
- 27608-27611 (4 pages)
- PDF File:
-
97-13089.pdf
