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 StevenK966@aol.com.
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]
BILLING CODE 6820-34-M
Document Information
- Published:
- 08/17/1999
- Department:
- General Services Administration
- Entry Type:
- Notice
- Action:
- Guideline on automating medical standard forms.
- Document Number:
- 99-21321
- Pages:
- 44736-44737 (2 pages)
- PDF File:
-
99-21321.pdf