[Federal Register Volume 64, Number 97 (Thursday, May 20, 1999)]
[Notices]
[Page 27554]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-12707]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 505

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 505
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                                    Item                                                 Placement *
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Text:
    Title: History--Parts 2 and 3..........................................  Top of form.
    Form ID: Standard Form 505 (Rev. 7-91).................................  Bottom right corner of form.
Data Entry Fields:
    Instructions (Include (1) Occupation (Civilian and military), (2)
     Military History (Include geographic locations and dates), (3) Habits
     (Alcohol, tobacco and drugs) (4) Family History, (5) Childhood
     Illnesses, (6) Adult Illnesses (7) Operations, (8) Injuries and (9)
     Drug Sensitivities and Allergic Reactions.
    Instructions (Include (1) General, (2) Head (including (3) Eye, (4)
     Ear, (5) Nose and Throat), (7) Neck, (8) Respiratory, (9)
     Cardiovascular, (10) Gastrointestinal, (11) Geniot-Urinary and (12)
     Gynecological, (13) hemopoietic, (14) Lymphatic, (15) Musculo-Skeletal
     and (16) Nero-Psychiatric Systems.
    Signature of Physician.
    Date (of Signature)....................................................
    Patient's Name--(last, first, middle)..................................  Bottom left corner of form.
    Patient's Grade.
    Patient's Rank.
    Patient's Rate.
    Patient's Hospital or Medical Facility.
    Register No.
    Ward No.
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* If no placement indicated, items can appear anywhere on the form.

FOR FURTHER INFORMATION CONTACT: CDR Steven S. Kerrick, USN, National 
Naval Medical Center, Department of Ophthalmology, Bethesda, MD 20889-
5000 or E-Mail at StevenK[email protected].

    Dated: May 12, 1999.
Steven S. Kerrick,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 99-12707 Filed 5-19-99; 8:45 am]
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