[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*
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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.
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*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]
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