1-15. DIAGNOSTIC TEST RESULTS (REPORTS)
When a patient is admitted to the hospital, the physician must enter the proposed
diagnostic workup in the Doctor's Progress Notes. The physician orders these tests on
DA Form 4256. The nurse must note the physician's orders for diagnostic tests and enter
the time the patient is sent for the tests in the Nursing Notes. The most common diagnostic
tests include: blood analysis, urinalysis, radiology (X-rays), and electrocardiogram (EKG).
The results of these diagnostic tests must be sent back to the ward for inclusion in the
patient's ITR; the doctor may annotate the results in the Doctor's Progress Notes.
1-16. SPECIAL REQUIREMENTS
If the patient is a surgical or obstetrical patient, additional forms and reports are
a. Surgery or Special Procedures. The forms required for surgery or special
operation, including the operation performed, the types of sutures used, gross findings, and
other relevant data.
pathological report is required. This form is used to describe the findings of the
(3) SF 522 (Request for Administration of Anesthesia and for Performance of
authorization or consent form. The patient must sign it to authorize surgery, and the
physician must sign it to indicate that he has counseled the patient about the proposed
describe the administration of anesthesia and to provide a preanesthetic summary.
b. Obstetrical and Newborn.
(1) Two forms are required for the mother when delivering a baby. They are SF
533 (Prenatal Record) and SF 534 (Labor Record).
(2) A newborn baby must have a birth certificate. The birth certificate is a local
form established by the state where the child is born.