98-15246. Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 536

[Federal Register Volume 63, Number 110 (Tuesday, June 9, 1998)]
[Notices]
[Pages 31480-31481]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 98-15246]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 536

AGENCY: General Services Administration.

ACTION: Guideline on Automating Medical Standard Forms.

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BACKGOUND: 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 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:

[[Page 31481]]



                     Electronic Elements for SF 515                     
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                 Item                              Placement *          
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Text:                                                                   
    Title: Pediatric Nursing Notes....  Top of form.                    
    Form ID: Standard Form 536 (Rev. 2- Bottom right corner of form.    
     95).                                                               
Data entry fields:                                                      
    Date Hour                                                           
    Temp Wt.                                                            
    Diet                                                                
    Amt. Taken                                                          
    Vomited                                                             
    Urine                                                               
    Stools                                                              
    Treatments, Medications                                             
    Nursing Notes                                                       
    Patient's Name--last, first,        Bottom left corner of form.     
     middle.                                                            
    Patient's ID No. or SSN                                             
    Hospital or Medical Facility                                        
    Register No.                                                        
    Ward No.                                                            
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*If no placement indicated, items can appear anywhere on the 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. 98-15246 Filed 6-8-98; 8:45 am]
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