d. Make each entry concise, complete, and legible. Include a description of the
nature and history of the patient's chief complaint or condition, the findings of any
examination or test, the diagnosis if one was made, any treatment rendered, any drugs
prescribed, the disposition of the patient, and any instructions given to the patient for
subsequent or follow-up care. Enter descriptions of injuries in a "how-when-where-
leave status" format. An entry for an emergency patient must include the means by
which the patient arrived and the condition of the patient at the time of disposition.
e. If you make an error on the form, draw a single line through the error (the
error must remain readable), enter your initials above the lined-out entry, and enter the
correct information following the lined-out entry. Do not erase the mistake or mark
through the mistake so as to make the error illegible.
f. Record the patient's complaint even if the patient is returned to duty (RTD) without
treatment. If the patient departs prior to being seen by medical personnel, record this
g. If a patient is assigned to quarters, include an estimate of the length of time
the patient will remain in this status.
h. Sign or initial each entry you make on the form. When a person makes his
first entry on the page, he must write his full signature block (name, rank, corps/status).
Later entries made by the same person on the same page can be initialed. The
signature block of the person making the entry may be stamped onto the form, but the
person making the entry must still sign or initial the entry.
i. When there is no more space left on a patient's SF 600, initiate another SF
600 and continue the entry, if appropriate.
j. File Chronological Record of Medical Care forms with the more recent form
Section III. THE OUTPATIENT TREATMENT RECORD
A record is maintained for each individual who has received outpatient treatment
at a military medical or dental treatment facility. Usually, this record is the HREC.
Records, however, must also be kept on people for whom a HREC is not authorized
(military dependents, civilian employees of the Federal Government, etc.) or whose
HRECs are no longer active (retired military personnel). An OTR is prepared for these
categories of patients. The health component of the OTR is maintained at the facility
providing primary health care (US Army health clinic). The dental component is
maintained at the facility providing primary dental care (US Army dental clinic). Upon
request, the patient may be given a copy of the permanent parts of his OTR.