NURSING UNIT FORMS AND THE INPATIENT TREATMENT RECORD
INPATIENTS AND OUTPATIENTS
Patients can be divided into two groups--inpatients and outpatients. Inpatients
are 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.
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.
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
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