[Federal Register Volume 67, Number 37 (Monday, February 25, 2002)]
[Notices]
[Page 8541]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-4452]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 519A

AGENCY: Office of Communications, GSA.

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 proposed 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 or delete 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 of 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 519A
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                   Item                             Placement \1\
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Radiologic consultation request/report....  Top of form.
Standard Form 519A (Rev. 8/1983)(Form ID).  Bottom right corner of form.
1-Medical Record..........................  Bottom left corner of form.
2-Physician...............................  Bottom left corner of form.
3-Radiology...............................  Bottom left corner of form.
Data Entry Fields:
Patient information (Text)                  Above below listed items.
Last name
First name
Middle name
Medical facility
Age
Sex
SSN (Sponsor)
Ward/clinic
Register No.
Examination requested (Use SF 519B for
 multiple exams)
Requested by
Telephone number
Location of medical records
Film number
Date requested
Pregnant--Yes (Checkbox)
Pregnant--No (No)
Specific reason(s) for Request (Complaints
 and findings)
Date of examination (Month, day, year)
Date of report (Month, day, year)
Date of transcription (Month, day, year)
Radiologic report
Signature
Location of radiologic facility
------------------------------------------------------------------------
\1\ If no specific placement, data element may be in any order.


FOR FURTHER INFORMATION CONTACT: CDR Katherine Ciacco Palatianos, 
Indian Health Service, Department of Health and Human Services, 5600 
Fishers Lane, Room 6A-55, Rockville, MD 20857 or E-Mail at 
[email protected].

DATES: Effective February 25, 2002.

    Dated: February 12, 2002.
CDR Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 02-4452 Filed 2-22-02; 8:45 am]
BILLING CODE 6820-34-M