[Federal Register Volume 64, Number 97 (Thursday, May 20, 1999)]
[Notices]
[Pages 27557-27558]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-12709]


-----------------------------------------------------------------------

GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard For 551

AGENCY: General Services Administration.

ACTION: Guideline on automating Medical standard forms.

-----------------------------------------------------------------------

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 
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 551
----------------------------------------------------------------------------------------------------------------
                                    Item                                                 Placement *
----------------------------------------------------------------------------------------------------------------
Text
    Title: Serology........................................................  Bottom right corner of form.
    Form ID: Standard Form 551 (Rev. 6-77).................................  Bottom right corner of form.
    Test(s)
    Speciment Taken........................................................  Under ``Test(s)''.
Data Entry Fields:
    Specimen Lab Rpt. No.
        Urgency--Routine (Check box).
        Urgency--Today (Check box).
        Urgency--Pre-Op (Check box).
        Urgency--Stat (Check box).
        Patient Status--Bed (Check box).
        Patient Status--Amb. (Check box).
        Outpatient--NP (Check box).
        Outpatient--DOM (Check box).
        Specimen Source--Blood (Check box).
        Specimen Source--Other (Check box).
        Specimen Source--Other (Specify).
        Requesting Physician's Signature.
        Reported By--MD.
        Reported By--Tech.
        Date (Reported).
        Lab ID No.
        Remarks.
        Date (Specimen Taken).
        Time (Specimen Taken).
        Requested--Inf. Mono. Qual. (Check box).
        Results--Inf. Mono. Qual.

[[Page 27558]]

 
        Requested--Inf. Mono. Quant. (Check box).
        Results--Info. Mono. Quant.
        Requested--RPR--Auto (Check box).
        Requested--RPR--Card (Check box).
        Results--RPR--Auto or Card.
        Requested--VDRL Quanl. (Check box)
        Results--BDRL Quanl.
        Requested--VDRL Quant. (Check box).
        Results--VDRL Quant.
        Requested--FTA-ABS (Check box).
        Results--FTA-ABS.
        Requested--TPHA (Check box).
        Results--TPHA.
        Requested--Rheumatoid Factor (Check box).
        Results--Rheumatoid Factor.
        Requested--Anti-Nuclear Factor (ANF) (Check box).
        Results--Anti-Nuclear Factor (ANF).
        Requested--Cold Agg. (Check box).
        Results--Colg Agg.
        Requested--ASO (Check box).
        Results--ASO.
        Requested--CPR (Check box).
        Results--CPR.
        Requested--Serum Complement (Check box).
        Results--Serum Complement.
        Requested--Febrile AGG (Check box).
        Results--Febrile AGG.
        Requested--Comp. Fix. (Check box).
        Results--Comp. Fix.
        Requested--HAI (Check box).
        Results--HAI.
        Requested--Thyroglobulin Antibody (Check box).
        Results--Thyroglobulin Antibody.
        Requested--Thyroid Microsomal Antibody (Check box).
        Results--Thyroid Microsomal Antibody.
        Patient's Identification...........................................  Upper left corner of form.
        Treatment Facility.................................................      Do.
        Ward No............................................................      Do.
        Date...............................................................      Do.
----------------------------------------------------------------------------------------------------------------
* If no placement indicated, items can appear anywhere on the form.

FOR FURTHER INFORMATION CONTACT: CMD 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. 99-12709 Filed 5-19-99; 8:45 am]
BILLING CODE 6820-34-M