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Integrated Publishing
Army Medical
- Medical Records and Sick Call Procedures
- Development
- Table of Contents
- Introduction
- Credit Awarded
- Lesson Assignment
- Lesson 1. Nursing Unit Forms and the Inpatient Treatment Record
- Permanent and Temporary Forms
- Figure 1-1. DA Form 3872, Nursing Service Personnel Time Schedule.
- Figure 1-2. DA Form 4015, Nursing Care Assignment.
- Temperature, Pulse and Respiration Record (DA Form 3950)
- Figure 1-3. DA Form 3950, Temperature, Pulse and Respiration Record.
- Figure 1-4. DD Form 792, Twenty-Four Hour Patient Intake and Output Worksheet (top [intake] section).
- Figure 1-5. DD Form 792, Twenty-Four Hour Patient Intake and Output Worksheet (bottom [output] section).
- Definitions of Intake and Output
- Table 1-1. Converting to millimeters (or cubic centimeters).
- Intravenous Intake
- Irrigation Intake
- Grand Total Intake
- Chest Output.
- Vital Signs Record (SF 511)
- Patient's Identification Section
- Figure 1-6. SF 511, Vital Signs Record.
- Figure 1-7. Partially completed SF 511.
- Month-Year/Day.
- Pulse Rate
- Blood Pressure
- Temperature
- Respiration Rate
- Height, Weight, and Special Data
- Nursing Assessment and Care Plan (DA Form 3888 and 3888-1)
- Figure 1-8. DA Form 3888, Nursing Assessment and Care Plan (front).
- Figure 1-9. DA Form 3888, Nursing Assessment and Care Plan (reverse).
- Figure 1-10. DA Form 3888-1, Nursing Assessment and Care Plan Continuation (front).
- Figure 1-11. DA Form 3888-1, Nursing Assessment and Care Plan Continuation (reverse)
- Figure 1-12. DA Form 4256, Doctor's Orders.
- Figure 1-13. DA Form 4677, Therapeutic Documentation Care Plan (Non-Medications) (front)
- Figure 1-14. DA Form 4677, Therapeutic Documentation Care Plan (Non-Medications) (reverse)
- Nursing Notes
- Figure 1-15. SF 510, Nursing Notes.
- Figure 1-16. SF 510, Nursing Notes, showing an admitting entry.
- Making Special Entries on the Nursing Notes
- Confidentiality
- Exercises
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Solutions to Exercises
- Solutions to Exercises (cont)
- Lesson Assignment
- Lesson 2. Outpatient Records.
- Section II. The Health Record
- Initiating a Health Record
- Right Side of File Folder.
- Right Side of File Folder (cont)
- Access to Health Records
- Filing, Transfer,and Disposition of Health Records
- Chronological Record of Medical Care
- Figure 2-1. SF 600, Chronological Record of Medical Care.
- Section III. The Outpatient Treatment Record
- Contents of Outpatient Treatment Records
- Right Side of File Folder.
- Filing Procedures
- Exercises
- Exercises (cont)
- Exercises (cont)
- Exercises (cont)
- Solutions to Exercises
- Lesson Assignment
- Lesson 3. Terminal Digit Filing System.
- Table 3-1. Family member prefix codes.
- Filing Sequence
- Table 3-2. Identification of DA Form 3444-series file folders.
- Figure 3-1. DA Form 3444-series file folder (DA Form 3444-2).
- Figure 3-2. Series of DA Form 3444-series records showing a misfiled record.
- Initiating a DA Form 3444-series folder
- Exercises
- Exercises (cont)
- Exercises (cont)
- Solutions to Exercises
- Lesson Assignment
- Lesson 4. Field Medical Card.
- Figure 4-1. DD Form 1380, US Field Medical Card.
- Initiating a Field Medical Card
- Entering Additional Information on a Field Medical Card
- Initial Disposition of the Field Medical Card
- Completing a Field Medical Card
- Completing a Field Medical Card (cont)
- Supplemental Field Medical Card
- Exercises
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Solutions to Exercises
- Lesson Assignment
- Lesson 5. Sick Call Procedures.
- Figure 5-1. DD Form 689, Individual Sick Slip.
- The Sick Call Interview
- Complaint of Pain.
- Levels of Care in the Algorithm-Directed Troop Medical Care System
- Figure 5-2. DA Form 5181-R, Screening Note of Acute Medical Care.
- Using the Algorithm-Directed Troop Medical Care System
- Select Appropriate Algorithm
- Example of a Patient Interview Using Algorithm-Directed Troop Medical Care System
- Figure 5-3. Algorithm TD-21: Cold (text).
- Figure 5-4. Algorithm TD-21: Cold (flow chart).
- Figure 5-5. Algorithm TD-15: Sore throat (text).
- Figure 5-6. Algorithm TD-15: Sore throat (flow chart).
- Emergency Treatment
- Prepare for Emergencies.
- Perform Follow-up Measures
- Exercises
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Exercises (Cont)
- Solutions to Exercises
Medical Records and Sick Call Procedures
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