68 FR 63 pgs. 16056-16059 - Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 88
Type: NOTICEVolume: 68Number: 63Pages: 16056 - 16059
FR document: [FR Doc. 03-7927 Filed 4-1-03; 8:45 am]
Agency: General Services Administration
Official PDF Version: PDF Version
GENERAL SERVICES ADMINISTRATION
Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 88
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 to 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 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 any exception. The following fields must appear on the electronic version of the following form:
| Item | Placement* |
|---|---|
| Report of Medical Examination | Top of form. |
| Standard Form 88 (Rev. 8/2001) (Form ID) | Bottom right corner of form. |
| Data Entry Fields: | |
| 1. Date of Exam | |
| 2. Last Name | |
| 2. First Name | |
| 2. Middle Name | |
| 3. Identification Number | |
| 4. Grade of Position | |
| 4. Component of Position | |
| 5. Home Address (Number, street or RDFD, city or town, state and ZIP code) | |
| 6. Emergency Contact (Name) | |
| 6. Emergency Contact (address) | |
| 7. Date of Birth | |
| 8. Age | |
| 9. Sex-Female (Checkbox) | |
| 9. Sex-Male (Checkbox) | |
| 10. Relationship of Contact | |
| 11. Place of Birth | |
| 12. Agency | |
| 13. Organization Unit | |
| 14a. Total Years Government Service-Military | |
| 14b. Total Years Government Service-Civilian | |
| 15. Name of Examining Facility or Examiner | |
| 15. Address of Examining Facility or Examiner | |
| 16. Rating or Specialty of Examiner | |
| 17. Purpose of Examination | |
| 18. Clinical Evaluation-Check each item in appropriate columns; enter "NE" if not evaluated | Above below listed items |
| a. Head, Face, Neck and Scalp-Normal (Checkbox) | |
| a. Head, Face, Neck and Scalp-Abnormal (Checkbox) | |
| b. Ears-General (Internal Canals) (auditory acuity under item 39)-Normal (Checkbox) | |
| b. Ears-General (Internal Canals) (auditory acuity under item 28t)-Abnormal (Checkbox) | |
| c. Drums (Perforations)-Normal (Checkbox) | |
| c. Drums (Perforations)-Abnormal (Checkbox) | |
| d. Nose-Normal (Checkbox) | |
| d. Nose-Abnormal (Checkbox) | |
| e. Sinuses-Normal (Checkbox) | |
| e. Sinuses-Abnormal (Checkbox) | |
| f. Mouth and Throat-Normal (Checkbox) | |
| f. Mouth and Throat-Abnormal (Checkbox) | |
| g. Eyes-General (Visual accuity and refraction under item 28li-28s)-Normal (Checkbox) | |
| g. Eyes-General (Visual accuity and refraction under item 28li-28s)-Abnormal (Checkbox) | |
| h. Ophtalmoscopic-Normal (Checkbox) | |
| h. Ophtalmoscopic-Abnormal (Checkbox) | |
| i. Pupils (Equality and reaction)-Normal (Checkbox) | |
| i. Pupils (Equality and reaction)-Abnormal (Checkbox) | |
| j. Ocular Motility (Associated parallel movements nystagmus)-Normal (Checkbox) | |
| j. Ocular Motility (Associated parallel movements nystagmus)-Abnormal (Checkbox) | |
| k. Lungs and Chest-Normal (Checkbox) | |
| k. Lungs and Chest-Abnormal (Checkbox) | |
| l. Heart (Thrust, size, rhythm, sounds)-Normal (Checkbox) | |
| l. Heart (Thrust, size, rhythm, sounds)-Abnormal (Checkbox) | |
| m. Vascular System-Normal (Checkbox) | |
| m. Vascular System-Abnormal (Checkbox) | |
| n. Abdomen and Viscera (Include hernia)-Normal (Checkbox) | |
| n. Abdomen and Viscera (Include hernia)-Abnormal (Checkbox) | |
| o. Prostate (Over 40 or clinically indicated)-Normal (Checkbox) | |
| o. Prostate (Over 40 or clinically indicated)-Abnormal (Checkbox) | |
| p. Testicular-Normal (Checkbox) | |
| p. Testicular-Abnormal (Checkbox) | |
| q. Anus and Rectum (Hemorrhoids, Fistulae) (Hemocult Results)-Normal (Checkbox) | |
| q. Anus and Rectum (Hemorrhoids, Fistulae) (Hemocult Results)-Abnormal (Checkbox) | |
| r. Endocrine System-Normal (Checkbox) | |
| r. Endocrine System-Abnormal (Checkbox) | |
| s. G-U System-Normal (Checkbox) | |
| s. G-U System-Abnormal (Checkbox) | |
| t. Upper Extremities (Strength, range of motion)-Normal (checkbox) | |
| t. Upper Extremities (Strength, range of motion)-Abnormal (Checkbox) | |
| u. Feet-Normal (Checkbox) | |
| u. Feet-Abnormal (Checkbox) | |
| v. Lower Extremities (Except feet) (Strength, range of motion)-Normal (Checkbox) | |
| v. Lower Extremities (Except feet) (Strength, range of motion)-Abnormal (Checkbox) | |
| w. Spine, Other Musculoskeletal-Normal (Checkbox) | |
| w. Spine, Other Musculoskeletal-Abnormal (Checkbox) | |
| x. Identifying Body Marks, scars, Tattoos (Explain in Notes)-Normal (Checkbox) | |
| x. Identifying Body Marks, scars, Tattoos (Explain in Notes)-Abnormal (Checkbox) | |
| y. Skin, Lymphatics-Normal (Checkbox) | |
| y. Skin, Lymphatics-Abnormal (Checkbox) | |
| z. Neurologic (Equilibrium tests under item 28t)-Normal (Checkbox) | |
| z. Neurologic (Equilibrium tests under item 28t)-Abnormal (Checkbox) | |
| aa. Psychiatric (Specify any personality deviation)-Normal (Checkbox) | |
| aa. Psychiatric (Specify any personality deviation)-Abnormal (Checkbox) | |
| bb. Breasts-Normal (Checkbox) | |
| bb. Breasts-Abnormal (Checkbox) | |
| cc. Pelvic (Females only)-Normal (Checkbox) | |
| cc. Pelvic (Females only)-Abnormal (Checkbox) | |
| 19. Notes (Describe every abnormality in detail. Enter pertinent item number before each comment. Continue in item 29 and use additional sheets if necessary) | |
| 20. Dental-Acceptable (Checkbox) | |
| 20. Dental-Not Acceptable (Checkbox) | |
| 20. Dental-Not Acceptable (if checked, explain) | |
| 20. Dental-Dental Examination not done by Dental Officer | |
| 21. Remarks and Additional Dental Defects and Diseases | |
| 22. Test Results (Copies of results are preferred as attachments) | Above below listed items. |
| 22a. Urinalysis-Specific Gravity | |
| 22a. Urine Albumin | |
| 22a. Urine Sugar | |
| 22b. Syphilis Serology (Specify test used and results) | |
| 22c. EKG | |
| 22d. Blood Type and RH Factor | |
| 22e. Chest X-Ray or PPD (Place, date, film number and result) | |
| 22f. Other Tests | |
| 23. Relationship to Sponsor | |
| 24a. Sponsor's Name-Last | |
| 24b. Sponsor's Name-First | |
| 24c. Sponsor's Name-MI | |
| 24c. Sponsor's ID Number (SSN or Other) | |
| 25. Depart./Service | |
| 26. Hospital or Medical Facility | |
| 27. Records Maintained At | |
| Last Name-First Name-Middle Name | Top of back page. |
| Identification Number | Top of back page. |
| Number of Sheets Attached | Top of back page. |
| 28. Measurements and Other Findings | Above below listed items. |
| 28a. Height | |
| 28b. Weight | |
| 28c. Color Hair | |
| 28d. Color Eyes | |
| 28e. Build-Slender (Checkbox) | |
| 28e. Build-Medium (Checkbox) | |
| 28e. Build-Heavy (Checkbox) | |
| 28e. Build-Obese(Checkbox) | |
| 28f. Temperature | |
| 28g(1). Blood Pressure (Arm at heart level)-Sitting-Sys. | |
| 28g(1). Blood Pressure (Arm at heart level)-Sitting-Dias. | |
| 28g(2). Blood Pressure (Arm at heart level)-Recumbent-Sys. | |
| 28g(2). Blood Pressure (Arm at heart level)-Recumbent-Dias. | |
| 28g(3). Blood Pressure (Arm at heart level)-Standing (5 minutes)-Sys. | |
| 28g(3). Blood Pressure (Arm at heart level)-Standing (5 minutes)-Dias. | |
| 28h(1). Pulse (Arm at heart level)-Sitting | |
| 28h(2). Pulse (Arm at heart level)-Recumbent | |
| 28h(3). Pulse (Arm at heart level)-Standing-3 minutes | |
| 28h(4). Pulse (Arm at heart level)-After Exercise | |
| 28h(5). Pulse (Arm at heart level)-2 minutes after exercise | |
| 28i(1). Distant Vision-Right 20/ (number) | |
| 28i(1). Distant Vision-Right-Corrected to 20/ (number) | |
| 28i(2). Distant Vision-Left 20/ (number) | |
| 28i(2). Distant Vision-Left Corrected to 20/ (number) | |
| 28j(1). Refraction-Right-By | |
| 28j(1). Refraction-Right-S | |
| 28j(1). Refraction-Right-CX | |
| 28j(2). Refraction-Left-By | |
| 28j(2). Refraction-Left-S | |
| 28j(2). Refraction-Left-CX | |
| 28k(1). Near Vision-Right (Number) | |
| 28k(1). Near Vision-Right-Corrected To (Number) | |
| 28k(1). Near Vision-Right-By (Number) | |
| 28k(2). Near Vision-Left (Number) | |
| 28k(2). Near Vision-Left-Corrected To (Number) | |
| 28k(2). Near Vision-Left-By (Number) | |
| 28l(1). Heterophoria (Specify Distance)-ESO | |
| 28l(2). Heterophoria (Specify Distance)-EXO | |
| 28l(3). Heterophoria (Specify Distance)-RH | |
| 28l(4). Heterophoria (Specify Distance)-LH | |
| 28l(5). Heterophoria (Specify Distance)-Prism Division | |
| 28l(6). Heterophoria (Specify Distance)-Prism Conv. Ct. | |
| 28l(7). Heterophoria (Specify Distance)-PC | |
| 28l(8). Heterophoria (Specify Distance)-PD | |
| 28m(1). Accommodation-Right | |
| 28m(2). Accommodation-Left | |
| 28n(1). Field of Vision-Right | |
| 28n(2). Field of Vision-Left | |
| 28o. Color Vision (Test used and result) | |
| 28p. Night Vision (Test used and result) | |
| 28q(1). Depth Perception (Test used and score)-Uncorrected | |
| 28q(2). Depth Perception (Test used and score)-Corrected | |
| 28r. Red Lens Test | |
| 28s(1). Intraocular Tension-Right | |
| 28s(2). Intraocular Tension-Left | |
| 28t. Audiometer-Right Ear-500-512 | |
| 28t. Audiometer-Right Ear-1000-1024 | |
| 28t. Audiometer-Right Ear-2000-2048 | |
| 28t. Audiometer-Right Ear-3000-3096 | |
| 28t. Audiometer-Right Ear-4000-4096 | |
| 28t. Audiometer-Right Ear-6000-6144 | |
| 28t. Audiometer-Left Ear-500-512 | |
| 28t. Audiometer-Left Ear-100-1024 | |
| 28t. Audiometer-Left Ear-2000-2048 | |
| 28t. Audiometer-Left Ear-3000-3096 | |
| 28t. Audiometer-Left Ear-4000-4096 | |
| 28t. Audiometer-Left Ear-6000-6144 | |
| 28u. Psychological and Psychomotor (Tests used and score) | |
| 29. Notes (Continued) and Significant or Interval History | |
| 30. Summary of Defects and Diagnoses (List diagnoses with item numbers) | |
| 31. Recommendations-Further Specialist Examinations Indicated (Specify) | |
| 32. Physical Profile-P | |
| 32. Physical Profile-U | |
| 32. Physical Profile-L | |
| 32. Physical Profile-H | |
| 32. Physical Profile-E | |
| 32. Physical Profile-S | |
| 33. Examinee-Is Qualified for (Checkbox) | |
| 33. Examinee-Is Qualified for Explanation | |
| 33. Examinee-Is Not Qualified for (Checkbox) | |
| 33. Examinee-Is Not Qualified for Explanation | |
| 34. Physical Category-A | |
| 34. Physical Category-B | |
| 34. Physical Category-C | |
| 34. Physical Category-E | |
| 35. If Not Qualified, List Disqualifying Defects by Item Number | |
| 36. Typed or Printed Name of Physician | |
| 36. Signature of Physician | |
| 37. Typed or Printed Name of Physician | |
| 37. Signature of Physician | |
| 38. Typed or Printed Name of Dentist or Physician (Indicate which) | |
| 38. Signature of Dentist or Physician | |
| 39. Typed or Printed Name of Reviewing Officer or Approving Authority | |
| 39. Signature of Reviewing Officer or Approving Authority | |
| *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, Rockville, MD 20857 or e-mail at kciacco@hqe.ihs.gov.
Dated: March 21, 2003.
Katherine Ciacco Palatianos,
Chairperson, Interagency Committee on Medical Records.
[FR Doc. 03-7927 Filed 4-1-03; 8:45 am]
BILLING CODE 6820-34-M