[Federal Register Volume 68, Number 63 (Wednesday, April 2, 2003)]
[Notices]
[Pages 16056-16059]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-7927]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 88

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 to 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 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 any 
exception. The following fields must appear on the electronic version 
of the following form:

                      Electronic Elements for SF 88
------------------------------------------------------------------------
                  Item                              Placement*
------------------------------------------------------------------------
Report of Medical Examination...........  Top of form.
Standard Form 88 (Rev. 8/2001) (Form ID)  Bottom right corner of form.
Data Entry Fields:
    1. Date of Exam
    2. Last Name
    2. First Name
    2. Middle Name
    3. Identification Number
    4. Grade of Position
    4. Component of Position
    5. Home Address (Number, street or
     RDFD, city or town, state and ZIP
     code)
    6. Emergency Contact (Name)
    6. Emergency Contact (address)
    7. Date of Birth
    8. Age
    9. Sex--Female (Checkbox)
    9. Sex--Male (Checkbox)
    10. Relationship of Contact
    11. Place of Birth
    12. Agency
    13. Organization Unit
    14a. Total Years Government Service--
     Military
    14b. Total Years Government Service--
     Civilian
    15. Name of Examining Facility or
     Examiner
    15. Address of Examining Facility or
     Examiner
    16. Rating or Specialty of Examiner
    17. Purpose of Examination
    18. Clinical Evaluation--Check each   Above below listed items
     item in appropriate columns; enter
     ``NE'' if not evaluated
        a. Head, Face, Neck and Scalp--
         Normal (Checkbox)

[[Page 16057]]

 
        a. Head, Face, Neck and Scalp--
         Abnormal (Checkbox)
        b. Ears-General (Internal
         Canals) (auditory acuity under
         item 39)--Normal (Checkbox)
        b. Ears-General (Internal
         Canals) (auditory acuity under
         item 28t)--Abnormal (Checkbox)
        c. Drums (Perforations)--Normal
         (Checkbox)
        c. Drums (Perforations)--
         Abnormal (Checkbox)
        d. Nose--Normal (Checkbox)
        d. Nose--Abnormal (Checkbox)
        e. Sinuses--Normal (Checkbox)
        e. Sinuses--Abnormal (Checkbox)
        f. Mouth and Throat--Normal
         (Checkbox)
        f. Mouth and Throat--Abnormal
         (Checkbox)
        g. Eyes--General (Visual accuity
         and refraction under item 28li-
         28s)--Normal (Checkbox)
        g. Eyes--General (Visual accuity
         and refraction under item 28li-
         28s)--Abnormal (Checkbox)
        h. Ophtalmoscopic--Normal
         (Checkbox)
        h. Ophtalmoscopic--Abnormal
         (Checkbox)
        i. Pupils (Equality and
         reaction)--Normal (Checkbox)
        i. Pupils (Equality and
         reaction)--Abnormal (Checkbox)
        j. Ocular Motility (Associated
         parallel movements nystagmus)--
         Normal (Checkbox)
        j. Ocular Motility (Associated
         parallel movements nystagmus)--
         Abnormal (Checkbox)
        k. Lungs and Chest--Normal
         (Checkbox)
        k. Lungs and Chest--Abnormal
         (Checkbox)
        l. Heart (Thrust, size, rhythm,
         sounds)--Normal (Checkbox)
        l. Heart (Thrust, size, rhythm,
         sounds)--Abnormal (Checkbox)
        m. Vascular System--Normal
         (Checkbox)
        m. Vascular System--Abnormal
         (Checkbox)
        n. Abdomen and Viscera (Include
         hernia)--Normal (Checkbox)
        n. Abdomen and Viscera (Include
         hernia)--Abnormal (Checkbox)
        o. Prostate (Over 40 or
         clinically indicated)--Normal
         (Checkbox)
        o. Prostate (Over 40 or
         clinically indicated)--Abnormal
         (Checkbox)
        p. Testicular--Normal (Checkbox)
        p. Testicular--Abnormal
         (Checkbox)
        q. Anus and Rectum (Hemorrhoids,
         Fistulae) (Hemocult Results)--
         Normal (Checkbox)
        q. Anus and Rectum (Hemorrhoids,
         Fistulae) (Hemocult Results)--
         Abnormal (Checkbox)
        r. Endocrine System--Normal
         (Checkbox)
        r. Endocrine System--Abnormal
         (Checkbox)
        s. G-U System--Normal (Checkbox)
        s. G-U System--Abnormal
         (Checkbox)
        t. Upper Extremities (Strength,
         range of motion)--Normal
         (checkbox)
        t. Upper Extremities (Strength,
         range of motion)--Abnormal
         (Checkbox)
        u. Feet--Normal (Checkbox)
        u. Feet--Abnormal (Checkbox)
        v. Lower Extremities (Except
         feet) (Strength, range of
         motion)--Normal (Checkbox)
        v. Lower Extremities (Except
         feet) (Strength, range of
         motion)--Abnormal (Checkbox)
        w. Spine, Other Musculoskeletal--
         Normal (Checkbox)
        w. Spine, Other Musculoskeletal--
         Abnormal (Checkbox)
        x. Identifying Body Marks,
         scars, Tattoos (Explain in
         Notes)--Normal (Checkbox)
        x. Identifying Body Marks,
         scars, Tattoos (Explain in
         Notes)--Abnormal (Checkbox)
        y. Skin, Lymphatics--Normal
         (Checkbox)
        y. Skin, Lymphatics--Abnormal
         (Checkbox)
        z. Neurologic (Equilibrium tests
         under item 28t)--Normal
         (Checkbox)
        z. Neurologic (Equilibrium tests
         under item 28t)--Abnormal
         (Checkbox)
        aa. Psychiatric (Specify any
         personality deviation)--Normal
         (Checkbox)
        aa. Psychiatric (Specify any
         personality deviation)--
         Abnormal (Checkbox)
        bb. Breasts--Normal (Checkbox)
        bb. Breasts--Abnormal (Checkbox)
        cc. Pelvic (Females only)--
         Normal (Checkbox)
        cc. Pelvic (Females only)--
         Abnormal (Checkbox)
    19. Notes (Describe every
     abnormality in detail. Enter
     pertinent item number before each
     comment. Continue in item 29 and
     use additional sheets if necessary)
    20. Dental--Acceptable (Checkbox)
    20. Dental--Not Acceptable
     (Checkbox)
    20. Dental--Not Acceptable (if
     checked, explain)
    20. Dental--Dental Examination not
     done by Dental Officer
    21. Remarks and Additional Dental
     Defects and Diseases
    22. Test Results (Copies of results   Above below listed items.
     are preferred as attachments)
        22a. Urinalysis--Specific
         Gravity
        22a. Urine Albumin
        22a. Urine Sugar
        22b. Syphilis Serology (Specify
         test used and results)
        22c. EKG
        22d. Blood Type and RH Factor

[[Page 16058]]

 
        22e. Chest X-Ray or PPD (Place,
         date, film number and result)
        22f. Other Tests
    23. Relationship to Sponsor
    24a. Sponsor's Name--Last
    24b. Sponsor's Name--First
    24c. Sponsor's Name--MI
    24c. Sponsor's ID Number (SSN or
     Other)
    25. Depart./Service
    26. Hospital or Medical Facility
    27. Records Maintained At
    Last Name--First Name--Middle Name..  Top of back page.
    Identification Number...............  Top of back page.
    Number of Sheets Attached...........  Top of back page.
    28. Measurements and Other Findings.  Above below listed items.
    28a. Height
    28b. Weight
    28c. Color Hair
    28d. Color Eyes
    28e. Build--Slender (Checkbox)
    28e. Build--Medium (Checkbox)
    28e. Build--Heavy (Checkbox)
    28e. Build--Obese (Checkbox)
    28f. Temperature
    28g(1). Blood Pressure (Arm at heart
     level)--Sitting--Sys.
    28g(1). Blood Pressure (Arm at heart
     level)--Sitting--Dias.
    28g(2). Blood Pressure (Arm at heart
     level)--Recumbent--Sys.
    28g(2). Blood Pressure (Arm at heart
     level)--Recumbent--Dias.
    28g(3). Blood Pressure (Arm at heart
     level)--Standing (5 minutes)--Sys.
    28g(3). Blood Pressure (Arm at heart
     level)--Standing (5 minutes)--Dias.
    28h(1). Pulse (Arm at heart level)--
     Sitting
    28h(2). Pulse (Arm at heart level)--
     Recumbent
    28h(3). Pulse (Arm at heart level)--
     Standing--3 minutes
    28h(4). Pulse (Arm at heart level)--
     After Exercise
    28h(5). Pulse (Arm at heart level)--
     2 minutes after exercise
    28i(1). Distant Vision--Right 20/
     (number)
    28i(1). Distant Vision--Right--
     Corrected to 20/ (number)
    28i(2). Distant Vision--Left 20/
     (number)
    28i(2). Distant Vision--Left
     Corrected to 20/ (number)
    28j(1). Refraction--Right--By
    28j(1). Refraction--Right--S
    28j(1). Refraction--Right--CX
    28j(2). Refraction--Left--By
    28j(2). Refraction--Left--S
    28j(2). Refraction--Left--CX
    28k(1). Near Vision--Right (Number)
    28k(1). Near Vision--Right--
     Corrected To (Number)
    28k(1). Near Vision--Right--By
     (Number)
    28k(2). Near Vision--Left (Number)
    28k(2). Near Vision--Left--Corrected
     To (Number)
    28k(2). Near Vision--Left--By
     (Number)
    28l(1). Heterophoria (Specify
     Distance)--ESO
    28l(2). Heterophoria (Specify
     Distance)--EXO
    28l(3). Heterophoria (Specify
     Distance)--RH
    28l(4). Heterophoria (Specify
     Distance)--LH
    28l(5). Heterophoria (Specify
     Distance)--Prism Division
    28l(6). Heterophoria (Specify
     Distance)--Prism Conv. Ct.
    28l(7). Heterophoria (Specify
     Distance)--PC
    28l(8). Heterophoria (Specify
     Distance)--PD
    28m(1). Accommodation--Right
    28m(2). Accommodation--Left
    28n(1). Field of Vision--Right
    28n(2). Field of Vision--Left
    28o. Color Vision (Test used and
     result)
    28p. Night Vision (Test used and
     result)
    28q(1). Depth Perception (Test used
     and score)--Uncorrected
    28q(2). Depth Perception (Test used
     and score)--Corrected
    28r. Red Lens Test
    28s(1). Intraocular Tension--Right
    28s(2). Intraocular Tension--Left
    28t. Audiometer--Right Ear--500-512
    28t. Audiometer--Right Ear--1000-
     1024

[[Page 16059]]

 
    28t. Audiometer--Right Ear--2000-
     2048
    28t. Audiometer--Right Ear--3000-
     3096
    28t. Audiometer--Right Ear--4000-
     4096
    28t. Audiometer--Right Ear--6000-
     6144
    28t. Audiometer--Left Ear--500-512
    28t. Audiometer--Left Ear--100-1024
    28t. Audiometer--Left Ear--2000-2048
    28t. Audiometer--Left Ear--3000-3096
    28t. Audiometer--Left Ear--4000-4096
    28t. Audiometer--Left Ear--6000-6144
    28u. Psychological and Psychomotor
     (Tests used and score)
    29. Notes (Continued) and
     Significant or Interval History
    30. Summary of Defects and Diagnoses
     (List diagnoses with item numbers)
    31. Recommendations--Further
     Specialist Examinations Indicated
     (Specify)
    32. Physical Profile--P
    32. Physical Profile--U
    32. Physical Profile--L
    32. Physical Profile--H
    32. Physical Profile--E
    32. Physical Profile--S
    33. Examinee--Is Qualified for
     (Checkbox)
    33. Examinee--Is Qualified for
     Explanation
    33. Examinee--Is Not Qualified for
     (Checkbox)
    33. Examinee--Is Not Qualified for
     Explanation
    34. Physical Category--A
    34. Physical Category--B
    34. Physical Category--C
    34. Physical Category--E
    35. If Not Qualified, List
     Disqualifying Defects by Item
     Number
    36. Typed or Printed Name of
     Physician
    36. Signature of Physician
    37. Typed or Printed Name of
     Physician
    37. Signature of Physician
    38. Typed or Printed Name of Dentist
     or Physician (Indicate which)
    38. Signature of Dentist or
     Physician
    39. Typed or Printed Name of
     Reviewing Officer or Approving
     Authority
    39. Signature of Reviewing Officer
     or Approving Authority
------------------------------------------------------------------------
*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, 
Rockville, MD 20857 or e-mail at [email protected].

    Dated: March 21, 2003.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 03-7927 Filed 4-1-03; 8:45 am]
BILLING CODE 6820-34-M