CORRESPONDENCE COURSE
U.S. ARMY ACADEMY OF HEALTH SCIENCES
SUBCOURSE MD0920 EDITION 100
As a medical specialist assigned to an Army medical treatment facility or to a field unit, you want to do your best in providing care to your patients. One key to good patient care is communication. Many times this communication takes place through the use of forms, records, and reports.
The physician and other health care providers rely upon the accuracy of the forms that you prepare in determining the treatment that the patient will receive. You rely upon forms completed by other personnel concerning instructions for patient care.
An understanding of medical forms, records, and procedures is needed whether you are working on a nursing unit (ward) of a military hospital, in a clinic, or in a field unit.
———————-
Download Here
Medical Records and Sick Call Procedures
Length: 120 Pages
Estimated Hours to Complete: 8
Format: PDF file
Size: 4.7 MB
———————-
Anyone may take this course. However, to receive credit hours, you must be officially enrolled and complete an examination furnished by the Nonresident Instruction Branch at Fort Sam Houston, Texas. Enrollment is normally limited to Department of Defense personnel. Others may apply for enrollment, but acceptance is not guaranteed.
TABLE OF CONTENTS
INTRODUCTION
1 NURSING UNIT FORMS AND THE INPATIENT TREATMENT RECORD
2 OUTPATIENT RECORDS
Section I. Clinics
Section II. The Health Record
Section III. The Outpatient Treatment Record
3 TERMINAL DIGIT FILING SYSTEM
4 FIELD MEDICAL CARD
5 SICK CALL PROCEDURES
Sample
LESSON 1 Nursing Unit Forms and the Inpatient Treatment
Record.
TEXT ASSIGNMENT Paragraphs 1-1 through 1-19.
LESSON OBJECTIVES When you have completed this lesson, you should be able to:
1-1. Identify who should have an Inpatient Treatment
Record.
1-2. Identify forms maintained in the Inpatient
Treatment Record.
1-3. Identify information recorded on DA Form 3872, DA Form 3888, DA Form 3888-1, DA Form 3950, DA Form 4015, DA Form 4256, DA Form 4677, DD Form 792, SF 510, and SF 511.
1-4. Calculate fluid intake and output.
1-5. Enter information on DD Form 792.
1-6. Enter information on SF 510.
1-7. Enter information on SF 511.
SUGGESTION Work the lesson exercises at the end of this lesson before beginning the next lesson. These exercises will help you accomplish the lesson objectives.
NURSING UNIT FORMS AND THE INPATIENT TREATMENT RECORD
1-1. INPATIENTS AND OUTPATIENTS
Patients can be divided into two groups–inpatients and outpatients. Inpatientsare those patients who are admitted to a military medical treatment facility (MTF), usually a United States Army (US Army) medical center (MEDCEN) hospital or a US Army community hospital (USACH) of a US Army medical department activity
(MEDDAC).
Outpatients are those patients who are treated at a MTF, usually a medical or dental clinic, but are not admitted to a MTF. Outpatients are sometimes referred to as ambulatory patients.
1-2. MILITARY FORMS
Three general types of forms are discussed in this subcourse. Standard forms (SF) are those forms that have been approved for use by Federal agencies in general.
Department of Defense (DD) forms are those forms that have been approved for use by the departments and agencies of the Department of Defense. Department of the Army (DA) forms are those forms which have been approved for use throughout the
Department of the Army. If a question arises over whether a particular form is currently approved for use, Department of the Army Pamphlet 25-30, Consolidated Index of Army Publications and Blank Forms, should be consulted.
1-3. THE INPATIENT (CLINICAL) TREATMENT RECORD
An MTF, sometimes called the Clinical Treatment Record, is prepared for every military and civilian patient admitted to the MTF (hospital, fixed health clinic, or convalescent center), for each live born infant delivered in the facility, for all North Atlantic Treaty Organization (NATO) personnel treated at the facility, and for carded-for-record-only (CRO) cases. A patient’s MTF consists of all permanent forms prepared on the patient during his uninterrupted period of treatment. AR 40-66, Medical Record and Quality Assurance Administration, contains instructions for filing forms in the DA Form 3444-series file folder used to maintain MTFs Inpatient Treatment Record (ITR). Inpatient Treatment Records are filed using the terminal digit filing system discussed in
Lesson 3.
a. Transfer of Inpatient Treatment Record. When an inpatient is transferred to another US military MTF, the patient’s original MTF is sent with the patient and becomes part of the patient’s MTF maintained at the receiving facility.
b. Retirement of Inpatient Treatment Record. When a patient is discharged (released from the facility, transferred to a nonmilitary MTF, or dies), the patient’s MTF is completed in accordance with AR 40-66. An MTF Cover Sheet, DA Form 3647 or DA Form 3647-1, summarizing the treatment provided is filed in the patient’s permanent MD0920 1-2
outpatient medical record (Health Record [HREC] or Outpatient Treatment Record [OTR]). The MTF is maintained by the facility for a specified time (usually 1 year for a USACH or 5 years for a MEDCEN) and then retired in accordance with AR 340-18, The Army Functional File System.