[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                                         
----------------------------------------------------------------------------------------------------------------
                        Item                                                  Placement*                        
----------------------------------------------------------------------------------------------------------------
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                                                                        
----------------------------------------------------------------------------------------------------------------
* 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