[Federal Register Volume 67, Number 198 (Friday, October 11, 2002)]
[Notices]
[Pages 63429-63430]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 02-25919]


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GENERAL SERVICES ADMINISTRATION

Interagency Committee for Medical Records (ICMR)


Automation of Medical Standard Form 504

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 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 required 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 504
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                     Item                                                  Placement *
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History--Part 1 (Title).......................  Top of form.
Standard Form 504 (Rev. 8/2001) (Form ID).....  Bottom right corner of form.

[[Page 63430]]

 
Data Entry Fields:
    Nature and Duration of Complaints (Include
     circumstances of admission)
 History of Present Illnesses
 Relationship to Sponsor
 Sponsor's Name--Last
 Sponsor's Name--First
 Sponsor's Name--MI
 Sponsor's ID Number (SSN or Other)
 Department/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
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* 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].

    Dated: February 12, 2002.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 02-25919 Filed 10-10-02; 8:45 am]
BILLING CODE 6820-34-M