[Federal Register: November 24, 1999 (Volume 64, Number 226)]
[Notices]               
[Page 66190-66191]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr24no99-75]                         

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GENERAL SERVICES ADMINISTRATION

 
Interagency Committee for Medical Records (ICMR); Automation of 
Medical Standard Form 525

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/
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 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:

                     Electronic Elements for SF 525
------------------------------------------------------------------------
             Item                              Placement*
------------------------------------------------------------------------
TEXT:
    Title: Radiation Therapy   Bottom right corner of form.
     Summary.
    Form ID: Standard Form     Bottom right corner of form.
     525 (Rev. 5-99).
    Full Figure front and
     back
    Head--profile--left and
     right
DATA ENTRY FIELDS:
    Diagnosis

[[Page 66191]]


    Sex
    Age
    Date of Consultation
    Narrative Summary--
     INSTRUCTIONS:
        Include (1) Site of
         primary and
         histopathology, (2)
         Clinical state or
         class (or exact area
         if treated for
         metastasis only),
         (3) Brief history,
         (4) Pertinent lab or
         X-ray findings, (5)
         Physical findings,
         (6) Plan of
         treatment, (7) Dates
         start and end, (8)
         Tumor does summary
         (include special
         techniques or
         precautions), (9)
         Status of tumor at
         completion of
         therapy, (10)
         Tollerance (include
         medications), (11)
         Disposition.
    Signature of Physician
    Date (of Signature)
    Relationship to Sponsor
    Sponsor's Name--Last
    Sponsor's Name--First
    Sponsor's Name--MI
    Sponsor's ID Number (SSN
     or Other)
    Depart./Service
    Organization
    Hospital or Medical
     Facility
    Records Maintained At
    Patient's Identification   Lower left corner of former.
        (Name--last, first,    Lower Left corner of form
         middle; ID No. or
         SSN; Sex; Date of
         Birth; Rank/Grade
    Register No..............  Lower Left corner of form.
    Ward No..................  Lower Left corner of form.
    Unit Parameters--Field
     (Allow at least 6
     entries)
    Unit Parameters--Unit
     (Allow at least 6
     entries)
    Unit Parameters--
     Nomenclature (Allow at
     least 6 entries)
    Unit Parameters--Beam
     Energy (Allow at least 6
     entries)
    Unit Parameters--
     Calibration Factors
     (Allow at least 6
     entries)
    Unit Parameters--Other
     Applicable Factors
     (Allow at least 6
     entries)
    Treatment Factors--Field
     Name (Allow at least 4
     entries)
    Treatment Factors--Field
     Size (Allow at least 4
     entries)
    Treatment Factors--SSD/
     TSD (Allow at least 4
     entries)
    Treatment Factors--Angel/
     ARC (Allow at least 4
     entries)
    Treatment Factors--Given
     Dose (Allow at least 4
     entries)
    Time Dose--Point Name
     (Allow at least 4
     entries)
    Time Dose--Dose (Allow at
     least 4 entries)
    Time Dose--Franctions
     (Allow at least 4
     entries)
    Time Dose--Days (Allow at
     least 4 entries)
    Time Dose--Inclusive
     Dates (Allow at least 4
     entries)
------------------------------------------------------------------------
* If no placement indicated, items can appear anywhere on the form.

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

    Dated: November 15, 1999.
Steven S. Kerrick,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 99-30600 Filed 11-23-99; 8:45 am]
BILLING CODE 6820-34-M