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.
1-4.
PERMANENT AND TEMPORARY FORMS
Some of the forms that a medical specialist may encounter while working on a
hospital ward (unit) are discussed in this lesson. Some of these forms are permanent.
That is, they become part of the patient's MTF. Other forms are temporary and can be
destroyed once the information has been transferred to another form or when the form
is no longer needed. Paragraphs 1-5 through 1-10 pertain to temporary forms and
paragraphs 1-11 through 1-18 pertain to permanent records. Permanent forms are
often kept in metal folders (charts) maintained on the ward. Each patient has a chart
containing his SF 510, SF 511, DA Form 4256, and DA Form 4677. DA Forms 3888
and 3888-1 may be maintained in separate charts.
1-5.
NURSING SERVICE PERSONNEL TIME SCHEDULE (DA FORM 3872)
The Nursing Service Personnel Time Schedule provides a roster of personnel,
shows on-duty and off-duty time, and explains the absences of nursing personnel from
the ward. The planning and preparation of the time schedule is the responsibility of the
clinical head nurse or other person designated by the Chief, Department of Nursing.
Time schedules are usually prepared and posted two weeks in advance. The
processes for submitting schedules and making changes are determined by local policy.
The form is retained as a reference for at least one month after the end of the period
covered and may be retained longer if required. The time schedule is destroyed when it
is no longer needed. Figure 1-1 shows an example of a time schedule. The symbols
"D," "E," and "N" stand for day, evening, and night respectively. The numbers show
how many professional (officer and civilian) and paraprofessional personnel (enlisted
and civilian) nursing personnel are on the day, evening, and night shifts.
1-6.
NURSING CARE ASSIGNMENT
The Nursing Care Assignment (DA FORM 4015) (figure 1-2) is a worksheet
initiated by the clinical head nurse or other designated personnel showing the specific
nursing care and related activities assigned to individual nursing personnel. It is
prepared daily and distributed at the time of shift change. The form assists nursing
personnel in organizing their work since each person knows the patients he has been
assigned and any special nursing care that must be given.
MD0920
1-3
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