Interagency Committee for Medical Records: Medical automation (SF 509); guidelines,

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Federal Register: May 20, 1999 (Volume 64, Number 97)NoticesPage 27552-27553From the Federal Register Online via GPO Access [wais.access.gpo.gov]

DOCID:fr20my99-68

GENERAL SERVICES ADMINISTRATION

Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 509

AGENCY: General Services Administration.

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 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) eleminited 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:

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Electronic Elements for SF 509

Item

Placement *

Text:

Title Progress Notes................................................... Bottom right corner of form.

Form ID: Standard Form 509 (Rev. 5-99)................................. Bottom right corner of form. Data Entry Fields:

Date (Allow at least 49 entries).

Notes (Allow at least 49 entries).

Relationship to Sponsor.

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.

Patient's Identification (Name--Last, first, middle; ID No. or SSN; Lower left corner of form. Sex; Date of Birth; Rank/Grade).

Ward No.

Register No.

* 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-Mial at StevenK966@aol.com.

Dated: May 12, 1999. Steven S. Kerrick, Chairperson, Interagency Committee on Medical Records.

FR Doc. 99-12705Filed5-19-99; 8:45 amBILLING CODE 6820-34-M

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