OUTPATIENT TREATMENT RECORDS (OTRs)
Section I. GENERAL
a. An Outpatient Treatment Record (OTR) is prepared for each patient treated as
an outpatient at a U.S. Army medical and dental treatment facility for whom a HREC is
not prepared. This record provides for a concise and complete record of diagnosis and
treatment for each civilian treated as an outpatient at an MTF. For dependents, it
provides a history of treatment.
b. In accordance with AR 40-5, OTRs are not prepared for civilians treated at
Army Federal Civilian Employee Health Service Clinics.
Medical and dental officers will ensure that information is promptly and accurately
recorded on OTR medical and dental forms. They will also ensure that records
prepared and received from other MTFs are promptly reviewed and filed in the OTR.
3-3. FORMS AND DOCUMENTS
a. DA Form 3444-Series are used as OTR file folders. The "Outpatient Treatment"
box is checked if the folder is used as a medical record and the "Dental (Nonmilitary)"
box if it is used as a dental record. Preparation and filing of DA Form 3444-Series file
folders is discussed in lesson 1.
b. The forms used in medical OTRs are listed in table 3-1. These forms are filed
from top to bottom in the order they are listed in the table. Copies of the same form are
grouped and filed in reverse chronological order (i.e., the latest on top). Retrieved files
are converted to this order; however, no attempt is made to convert an existing file until
it is retrieved and used.
c. SF 603, other medical and dental forms needed for dental care, and X-rays will
be included in dental OTRs.
d. The problem-oriented medical record (POMR) is authorized for optional use.
Local policy should prescribe the type of cases for which the POMR is used, personnel
(doctors, nurses, or others) who may use the POMR, and the placement of the Problem
List in the record.