[Federal Register Volume 67, Number 46 (Friday, March 8, 2002)]
[Notices]
[Pages 10729-10730]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-5546]


=======================================================================
-----------------------------------------------------------------------

GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR) Automation of 
Medical Standard Form 503

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 
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

[[Page 10730]]

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 503
------------------------------------------------------------------------
             Item                              Placement
------------------------------------------------------------------------
Autopsy Protocol (Title).....  Top of form.
Standard Form 503 (Rev. 7/     Bottom right corner of form.
 2000) (Form ID).
    Data Entry Fields:
    Date Died
    Hour Died
    Date Autopsy Performed
    Hour Autopsy Performed
    Prosector (Name)
    Assistant (Name)
    Full Autopsy (Checkbox)
    Head Only (Checkbox)
    Truck Only (Checkbox)
    Clinical Diagnosis
     (Including operations)
    Pathological Diagnosis
    Approved--Signature
    Military Organization
     (When required)
    Age
    Autopsy Number
    Relationship to Sponsor
    Sponsor's Name--Last
    Sponsor's Name--First
    Sponsor's Name--MI
    Sponsor's ID Number (SSN
     or other)
    Dept./Service
    Hospital or Medical
     Facility
    Records Maintained At
    Register No.
    Ward No.
Patient Information (Text)...  Above below listed items.
    Last Name
    First Name
    Middle Name
    Id No. or SSN
    Sex
    Date of Birth
    Rank/Grade
------------------------------------------------------------------------
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 March 8, 2002.

    Dated: February 12, 2002.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 02-5546 Filed 3-7-02; 8:45 am]
BILLING CODE 6820-34-M