[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]
-----------------------------------------------------------------------
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.
-----------------------------------------------------------------------
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
------------------------------------------------------------------------
Item Placement *
------------------------------------------------------------------------
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.
------------------------------------------------------------------------
*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]
BILLING CODE 6820-34-P