b. A routine Inpatient Treatment Record is required if a patient has a serious
illness, such as a heart attack or pneumonia.
c. A routine Inpatient Treatment Record is also required for a patient having major
d. Often, more than one of these criteria may be present. Major surgery generally
requires more than 72 hours of care. A serious illness may also require more than 72
hours of care, and a serious illness may also require major surgery.
ABBREVIATED MEDICAL RECORD
a. SF 539 (Abbreviated Medical Record) may be used for cases of a minor nature
that require no more than 72 hours' hospitalization. It may be used for accident cases held
for observation, removal of superficial growths, or application of plaster casts.
b. If general anesthesia is given, the surgical process must be localized and should
not entail a systemic invasion. SF 539 may be used for cases in which general anesthesia
is given only if the patient has no organic, physiologic, biochemical, or psychiatric
c. When military personnel are hospitalized for uncomplicated conditions not usually
requiring hospitalization for civilians, such as measles or upper respiratory infections, SF
539 will be used. If the hospital stay exceeds 72 hours, the reason for the extended stay
will be fully recorded in the progress notes and a narrative summary must be prepared.
CARDED FOR RECORD ONLY (CRO)
A case is carded for record only when a patient is not admitted to the hospital but
the preparation of a DA Form 3647 (Inpatient Treatment Record Cover Sheet) and the
assignment of a register number are required. Examples of CRO cases are:
a. Patients who are dead upon arrival (DOA) at the medical treatment facility.
b. Medical board examinations performed in an outpatient facility.
c. Certain other cases considered by the MTF to have medical, legal, or other
significance, such as rape, assault, and driving while intoxicated (DWI). The Medical
Records Committee establishes guidelines for these cases.