99-21321. Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 506

[Federal Register Volume 64, Number 158 (Tuesday, August 17, 1999)]
[Notices]
[Pages 44736-44737]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-21321]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 506

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-like images of the genuine paper Standard/Optional 
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 506
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                            Item                                                 Placement *
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Text:
    Title: Physical Examination............................  Top of form.
    Form ID: Standard Form 506 (Rev.)......................  Bottom right corner of form.
Data Entry Fields:
    Date of Exam
    Height
    Weight--Average
    Weight--Maximum
    Weight--Present
    Temperature
    Pulse
    Blood Pressure
    Instructions--Describe (1) General Appearance and
     Mental Status; (2) Head and Neck (General); (3) Eyes;
     (4) Ears; (5) Nose; (6) Mouth; (7) Throat; (8) Teeth;
     (9) Cheek (General); (10) Breast; (11) Lungs; (12)
     Cardiovascular; (13) Abdomen; (14) Hernia; (15)
     Genitalia; (16) Pelvic; (17) Rectal; (18) Prostate;
     (19) Back; (20) Extremities; (21) Neurological; (22)
     Skin; (23) Lymphatics.
    Relationship to Sponsor
    Sponsor's Name--Last
    Sponsor's Name--First
    Sponsor's Name--MI
    Sponsor's ID Number (SSN or other)
    Department/Service
    Hospital or Medical Facility
    Records Maintained At
    Physical Examination
    Initial Impression
    Signature of Physician
    Name of Physician

[[Page 44737]]

 
    Patient's Name--last, first, middle....................  Bottom left corner of form.
    Patient's ID No. or SSN................................    Do.
    Patient's Sex..........................................    Do.
    Patient's Date of Birth................................    Do.
    Patient's Rank/Grade...................................    Do.
    Register No............................................    Do.
    Ward No................................................    Do.
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* If no placement indicated, items can appear anywhere on the form.

FOR FURTHER INFORMATION CONTACT: CMD Steven S. Kerrick, National Naval 
Medical Center, Department of Ophthalmology, Bethesda, MC 20889-5000 or 
E-Mail at [e-mail].

    Dated: August 9, 1999.
CMD Steven S. Kerrick,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 99-21321 Filed 8-16-99; 8:45 am]
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