3-6.
DOCUMENT FLOW OF INPATIENT TREATMENT RECORD COVER SHEET
a. Initial Preparation. The ITRCS must be initiated in the Admission and
Disposition Office (AAD) when a patient is admitted, and Items 1 through 30 (except for
Items 25 and 26) are completed. Nonautomated sites will use DA Form 2985
(Admission and Coding Information) as a source document. At automated sites, the
ITRCS is computer-generated by the Automated Quality of Care Evaluation Support
System (AQCESS) or the Composite Health Care System (CHCS).
b. Initial Flow. Local procedures prescribe the flow of the ITRCS. In some
Army hospitals, the AAD sends the original and three copies of the ITRCS, along with
the Inpatient Treatment Record jacket and the Admission and Coding Form to the
inpatient record area for filing in a suspense file pending disposition of the patient. In
other hospitals, AAD maintains the suspense file on ITRCS and related forms until
disposition of the patient. Still other hospitals send the ITRCS to the ward for filing until
disposition of the patient. The worksheet copy (third copy) is always sent to the ward
for use by the health care provider and filed in the patient's chart.
c. Disposition Flow. When the patient is dispositioned, the worksheet copy of
the ITRCS is completed and signed by the health care provider. This worksheet and
other documents in the patient's chart are used to complete the other three copies of the
ITRCS. The personnel in the Medical Records Administration Branch are responsible
for reviewing the ITRCS for completeness and accuracy. The DA
Form 2985 (Admission and Coding Information) is completed from the ITRCS. The
copies of the completed ITRCS are then distributed in accordance with AR 40-66 and
AR 40-400.
MD0753
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