General Services Administration
Interagency Committee for Medical Records (ICMR)
AGENCY:
Office of Communications, GSA.
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 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:
| Item | Placement * |
|---|---|
| History—Part 1 (Title) | Top of form. |
| Standard Form 504 (Rev. 8/2001) (Form ID) | Bottom right corner of form. |
| ( printed 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 | |
| * 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 kciacco@hqe.ihs.gov.
Dated: February 12, 2002.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.