Interagency Committee for Medical Records (ICMR) Automation of Medical Standard Form 602

[Federal Register Volume 64, Number 114 (Tuesday, June 15, 1999)]
[Notices]
[Pages 32048-32051]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 99-15060]


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GENERAL SERVICES ADMINISTRATION


Interagency Committee for Medical Records (ICMR) Automation of 
Medical Standard Form 602

AGENCY: General Services Administration.

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/

[[Page 32049]]

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 form (if necessary). Activities may not add 
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 on Medical 
Records (ICMR) eliminated the requirement that every electronic version 
of a medical Standard/Option form be reviewed and granted an exception. 
The following fields must appear on the electronic version of the 
following form:

                     Electronic Elements for SF 602
------------------------------------------------------------------------
                     Item                             Placement *
------------------------------------------------------------------------
TEXT:
    Title Serology Record....................  Top of form.
    Form ID: Standard Form 602 (Rev. 8-98)...  Bottom right corner of
                                                form.
    Section I--History of Present Infection..  Top of form.
    I have been informed by the medical        Before patient's
     officer that I have been diagnosed as a    signature.
     having sexually transmitted disease as
     indicated above; the nature of this
     disease has been explained to me; I
     understand that my cooperation is
     necessary in the treatment and prolonged
     observation (including certain
     prescribed tests) for the care of this
     disease. Disclosure of this information
     is required by law.
    Section II--History of Past Sexually
     Transmitted Infections or Treatments
    Section III--Treatment
    Section IV--Laboratory Summary
    * Satisfactory result cannot be reported   Below Section V--
     without normal spinal fluid findings.      Evaluation of Therapy--
                                                Result--Satisfactory.*
    ** Specify: Infectious Relapse: Sero-      Below Section V--
     Relapse, Neuro-Relapse, Incomplete data    Evaluation of Therapy--
     on Spinal Fluid, Other (Specify.           Result--Unsatisfactory.*
                                                *
DATA ENTRY FIELDS:
    Source of Referral--Voluntary (Check box)
    Source of Referral--Contact Report (Check
     box)
    Source of Referral--Physical Inspection
     (Check box)
    Source of Referral--Blood Transfusion
     (Check box)
    Incident To--Hospitalization (Check box)
    Incident To--Premarital (Check box)
    Incident To--Prenatal (Check box)
    Incident To--Other (Check box)
    Incident To--Other (Specify)
    Dates--Onset Symptoms
    Dates--Requested Treatment
    Dates--Diagnosis Established
    Diagnostic (include stage and diagnosis
     number)
    Diagnostic Criteria--Darkfield (Results
     of test)
    Diagnostic Criteria--S.T.S. (Results of
     test)
    Diagnostic Criteria--Spinal Fluid (If
     indicated)
    Diagnostic Criteria--Other (List)
    Clinical Data (Include chief complaint,
     physical findings--eye, cardiovascular
     and nervous system, even in early
     syphilis)
    STD Contact Form Serial Numbers (allow
     for up to 3 numbera)
    Recommended Treatment
    Recommended Follow-up
    Signature of Physician
    Name of Physician
    Date (Signed by Physician)
    Signature of Patient
    Date (Patient Signed)
    Date (Of Treatment) (Allow at least 3
     entries)
    Disease (Give state) (Allow at least 3
     entries)
    Prior to Federal Service--Yes (Check box)
     (Allow at least 3 entries)
    Prior to Federal Service--No (Check box)
     (Allow at least 3 entries)
    History * * *--Treatment (Give type,
     amount and dates) (Allow at least 3
     entries)
    Treating Agency (Allow at least 3
     entries)
    Place (Institution and City) (Allow at
     least 3 entries)
    Treatment--Treatment (Allows for at least
     3 entries)
    Treatment--Date Started (Allow for at
     least 3 entries)
    Treatment--Date Ended (Allow for at least
     3 entries)
    Treatment--Signature of Physician (Allow
     for at least 3 entries)
    Relationship to Sponsor

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    Sponsor's Name--Last
    Sponsor's Name--First
    Sponsor's Name--MI
    Sponsor's ID Number (SSN or other)
    Depart./Service
    Hospital or Medical Facility
    Records Maintained At
    Darkfield Examination--Date (Allow for at
     least 2 entries)
    Darkfield Examination--Results (Allow for
     at least 2 entries)
    Darkfield Examination--Source of
     Speciment (Allow for at least 2 entries)
    Darkfield Examination--Laboratory (Allow
     for at least 2 entries)
    Darkfield Examination--Name of Confirming
     Officer (Allow for at least 2 entries)
    Nonspecific Treponenal Tests (VDRL, RPR,
     ART)--Date (Allow for at least 6
     entries)
    Nonspecific Treponenal Tests (VDRL, RPR,
     ART)--Type (Allow for at least 6
     entries)
    Nonspecific Treponenal Tests (VDRL, RPR,
     ART)--Result (Include titer value)
     (Allow for at least 6 entries)
    Nonspecific Treponenal Tests (VDRL, RPR,
     ART)--Laboratory (Allow for at least 6
     entries)
    Specific Treponenal Tests (FTA-ABS, MHA-
     TP, TPHA, TPI)--Date (Allow for at least
     2 entries)
    Specific Treponenal Tests (FTA-ABS, MHA-
     TP, TPHA, TPI)--Test Type (Allow for at
     least 2 entries)
    Specific Treponenal Tests (FTA-ABS, MHA-
     TP, TPHA, TPI)--Results (Allow for at
     least 2 entries)
    Spinal Fluid Examinations--Date (Allow
     for at least 2 entries)
    Spinal Fluid Examinations--Cells (Allow
     for at least 2 entries)
    Spinal Fluid Examinations--Total Protein
     (Allow for at least 2 entries)
    Spinal Fluid Examinations--Nonspecific
     And/Or Specific Tests (Including titer)
     (Allow for at least 2 entries)
    Spinal Fluid Examinations--Laboratory
     Where Done (Allow for at least 2
     entries)
    Section V--Evaluation of Therapy--Date
     (Allow for at least 3 entries)
    Section V--Evaluation of Therapy--
     Facility Where Evaluated (Allow for at
     least 3 entries)
    Section V--Evaluation of Therapy--Result--
     Satisfactory * (Check box) (Allow for at
     least 3 entries)
    Section V--Evaluation of Therapy--
     Result)--Unsatisfactory * (Allow for at
     least 3 entries)
    Section V--Evaluation of Therapy--Result--
     Date of Retreatment (Allow for at least
     3 entries)
    Section V--Evaluation of Therapy--Result--
     Physician's Signature (Allow for at
     least 3 entries)
    Reason for Incomplete Follow-Up--Date
    Reason for Incomplete Follow-Up--Place
    Reason for Incomplete Follow-Up--Type of
     Separation
    Reason for Incomplete Follow-Up--
     Authority For Discharge
    Reason for Incomplete Follow-Up--Civilian
     Health Department to Which Case Resume
     Was Sent
    Patient's Home Address on Separation--
     Street Address
    Patient's Home Address on Separation--
     City
    Patient's Home Address on Separation--
     State
    Patient's Home Address on Separation--ZIP
     Code
    Reinfection (Give date new record was
     opened)
    Remarks (Include significant post-
     treatment clinical findings)
    Section VI--Medical Officer Closing This
     Record--Name (Typed or printed)
    Section VI--Medical Officer Closing This
     Record--Signature
    Section VI--Medical Officer Closing This
     Record--Station
    Section VI--Medical Officer Closing This
     Record--Date
    Section VII--Medical Officer Sending
     Abstract to Department of Veterans
     Affairs on Discharge--Name (Typed or
     printed)
    Section VII--Medical Officer Sending
     Abstract to Department of Veterans
     Affairs on Discharge--Signature
    Section VII--Medical Officer Sending
     Abstract to Department of Veterans
     Affairs on Discharge--Station
    Section VII--Medical Officer Sending
     Abstract to Department of Veterans
     Affairs on Discharge--Date
    Patient's Name--last, first, middle).....  Bottom left corner of
                                                form.
    Patient's ID No. or SSN..................      Do.
    Patient's Rank/Grade.....................      Do.
    Patient's Date of Birth..................      Do.
    Register No..............................      Do.
    Ward No..................................      Do.
------------------------------------------------------------------------
* If no placement indicated, items can appear anywhere on the form.


[[Page 32051]]

FOR FURTHER INFORMATION CONTACT: CDR Steven S. Kerrick, National Naval 
Medical Center, Department of Ophthalmology, Bethesda, MD 20889-5000 or 
E-Mail at StevenK966@aol.com.

    Dated: May 12, 1999.
Steven S. Kerrick,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 99-15060 Filed 6-14-99; 8:45 am]
BILLING CODE 6820-34-M