c. Entries for Outpatient Care. SF 600 is used to record each visit to an MTF
for outpatient care as described in the following paragraphs:
(1) Entries on the SF 600 must be concise but complete. The entries must
be medically adequate as well as legally adequate. The entries should include:
(a) A description of the nature and history of the patient's chief
complaint or condition.
(b) The findings of any examination or test.
(c) The diagnoses and impressions, if made.
(d) The treatment, disposition, and any instructions given to the
patient for later or follow-up care. All prescribed drugs are recorded. These entries
may be recorded in a subjective, objective, assessment , plan (SOAP) format.
(2) Each visit is recorded and the complaint described even if the patient is
returned to duty without treatment. If a patient leaves before being seen, this is also
stated on the SF 600.
(3) When admission as an inpatient is imminent , the entries discussed in
paragraph (1) above may be made on SF 509 (Medical Record - Doctor's Progress
Notes) instead of SF 600. The SF 509 will then be the inpatient admission note filed in
the patient's inpatient record. For emergency room admission, SF 558 is the admission
note filed in the patient's Inpatient Treatment Record. Other referred or deferred
inpatient admissions are recorded on SF 600.
(4) All requests for consultation, prescriptions, or other services are recorded
on SF 600.
(5) When patients are seen repeatedly for special procedures or therapy,
(e.g., physical and occupational therapy, renal dialysis, or radiation), the therapy is
noted on SF 600 and interim progress statements are recorded. A final summary is
made when the special procedures or therapy are ended. This summary will include:
(a) Results of evaluative procedure
(b) Treatment given.
(c) Reaction to treatment.
(d) Progress noted.
(e) Condition on discharge.
(f) Any other pertinent observations.