[Federal Register: August 19, 1998 (Volume 63, Number 160)]
[Notices]               
[Page 44460-44461]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr19au98-58]

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GENERAL SERVICES ADMINISTRATION

 
Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 600

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 images of the genuine paper Standard 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 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/Optional form be reviewed and granted an 
exception. The following fields must appear on the electronic version 
of the following form:

[[Page 44461]]



                                         Electronic Elements for SF 600                                         
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                          Item                                                  Placement*                      
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                          TEXT                                                                                  
                                                                                                                
Title: Chronological Record of Medical Care............  Top of form.                                           
Form ID: Standard Form 600 (Rev. 6-97).................  Bottom right corner of form.                           
                                                                                                                
                   Data Entry Fields                                                                            
                                                                                                                
Date (of entry)                                                                                                 
    Symptons                                                                                                    
    Diagnosis                                                                                                   
    Treatment                                                                                                   
    Treating Organization                                                                                       
    Signature for each entry                                                                                    
    Hospital or Medical Facility                                                                                
    Status                                                                                                      
    Department/Service                                                                                          
    Records Maintained At                                                                                       
    Sponsor's Name                                                                                              
    Sponsor's SSN/ID No.                                                                                        
    Relationship to Sponsor                                                                                     
    Patient's Name--last, first, middle)...............  Bottom left corner of form.                            
    Patient's ID No. or SSN                                                                                     
    Patient's Sex                                                                                               
    Patient's Date of Birth                                                                                     
    Patient's Rank/Grade                                                                                        
    Register No.                                                                                                
    Ward No.                                                                                                    
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* If no placement indicated, items can appear anywhere on the form.                                             

FOR FURTHER INFORMATION CONTACT: CAPT Patricia Buss, MC, USN.

    Dated: August 11, 1998.
CAPT Patricia Buss, MC, USN,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 98-22243 Filed 8-18-98; 8:45 am]
BILLING CODE 6820-34-M