98-15245. Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 515

[Federal Register Volume 63, Number 110 (Tuesday, June 9, 1998)]
[Notices]
[Pages 31481-31482]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-15245]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 515

AGENCY: General Services Administration.

ACTION: Guideline on Automating Medical Standard Forms.

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BACKGROUND: The Interagency Committee on Medical Records (ICMR) is 
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 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 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 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 fields must appear on the electronic version 
of the following form:

                     Electronic Elements for SF 515                     
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                    Item                              Placement*        
------------------------------------------------------------------------
Text:                                                                   
    Title: Tissue Examination..............  Top of form.               
    Form ID: Standard Form 515 (Rev. 8-97).  Bottom right corner of     
                                              form.                     
Data entry fields:                                                      
    Specimen Submitted By                                               
    Date Obtained                                                       
    Specimen                                                            
    Brief Clinical History (Include                                     
     duration of lesion and rapidity of                                 
     growth, if a necoplasm)                                            
    Preoperative Diagnosis                                              
    Operative Findings                                                  
    Postoperative Diagnosis                                             
    Signature                                                           
    Name of Signer                                                      
    Title of Signer                                                     
    Pathological Report**                                               

[[Page 31482]]

                                                                        
    Name of Laboratory                                                  
    Accession No(s)***                                                  
    Gross Description, Histologic                                       
     Examination and Diagnoses                                          
    Signature of Pathologist                                            
    Name of Pathologist                                                 
    Date****                                                            
    Hospital or Medical Facility                                        
    Records Maintained At                                               
    Department/Service of Patient                                       
    Relation to Sponsor                                                 
    Sponsor's Name (Last, first, middle)                                
    Sponsor's ID Number (SSN or Other)                                  
    Patient's Name (last, first, middle)...  Bottom left.               
    Patient's ID No. or SSN................  Corner of form.            
    Patient's Sex..........................  (All items that            
    Patient's Date of Birth................  start with                 
    Patient's Rank/Grade...................  ``Patient's'')             
    Register No.                                                        
    Ward No.                                                            
------------------------------------------------------------------------
*If no placement indicated, items can appear anywhere on the form.      
**Optional title to cover next 6 items in list.                         
***Date Pathologist signed form.                                        

FOR FURTHER INFORMATION CONTACT: The Interagency Committee for Medical 
Records via General Services Administration (CARM); 1800 F Street, NW., 
Room 7136; Washington, DC 20405-0002.

    Dated: May 12, 1998.
Capt. Patricia Buss, MC, USN,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 98-15245 Filed 6-8-98; 8:45 am]
BILLING CODE 6820-34-M