[Federal Register Volume 68, Number 88 (Wednesday, May 7, 2003)]
[Notices]
[Pages 24479-24480]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 03-11217]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Record (ICMR); Automation of 
Medical Standard Form 603A

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 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 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 603A
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                      Item                                                 Placement *
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Dental--Continuation...........................  Top of form
Standard Form 603A (Rev. 11/2002) (Form ID)....  Bottom right corner of form.
Data Entry Fields:
    Section III. Attendance Record (text)......  Above items listed below.
    15. Restorations and Treatments (Completed   Above Items listed below.
     during service) (text).
        (Graphic of full set of teeth with each
         tooth numbered. Numbers will range
         from 1 to 32)
    Remarks
    16. Subsequent Diseases and Abnormalities..  Above items listed below.
        (Graphic of full set of teeth with each
         tooth numbered. Numbers will range
         from 1 to 32)
    Remarks
    17. Services Rendered (text)...............  Above Items listed below.
        Date (Allow for at least 21 entries)
        Diagnosis-Treatment (Allow for at least
         21 entries)
        Class (Allow for at least 21 entries)
        Operator and Dental Facility (Allow for
         at least 21 entries)
        Initials (Allow for at least 21
         entries)
Relationship to Sponsor
Sponsor's Name--Last
Sponsor's Name--First
Sponsor's Name--Middle Initial
Sponsor's Identification Number (Social
 Security Number or Other)
Department/Service
Hospital or Medical Facility
Records Maintained At
Register Number
Ward Number
 
If collected data covers more than one page,
 the following elements apply:
 
    Last Name..................................  Top of every even page.
    First Name.................................   Do.
    Middle Initial.............................   Do.
    ID Number..................................   Do.
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* If no specific placement, data element may be in any order.


[[Page 24480]]


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: April 24, 2003.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 03-11217 Filed 5-6-03; 8:45 am]
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