(3) Carded for record only (CRO).
(a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover
Sheet) are placed at the front of the folder.
(b) Then, other forms as applicable are filed (for example, a copy of the
death certificate for a DOA case).
* In facilities using the Composite Health Care System (CHCS) or Automated Quality of
Care Evaluation Support System (AQCESS), an automated version of DA Form 3647 will
be used. The worksheet copy will not be provided.
Section III. ESSENTIAL ELEMENTS
a. Content. Entries are made in a medical record by the health care provider
observing, treating, or caring for the patient. Entries on the Inpatient Treatment Record
Cover Sheet (ITR) or on any medical form provide a useful record for continued and future
care; therefore, all entries must be relevant to actual observation and treatment of the
patient, and the record must be current.
b. Legibility. All entries in the ITR must be legible. They should be in typewritten
form, when possible. When hand-written, entries must be made in permanent black or
blue-black ink; rubber stamps may be used only for standardized entries. Certain forms,
such as radiology, pathology, and operative reports, and the narrative summary, must be in
typewritten form. These are usually dictated and transcribed onto Optional Form 275
(Medical Record Report).
c. Signatures. All entries in the ITR must be signed; later entries on the same
page by the same person must be signed or initialed. A military member must add grade
and corps; a civilian must add title or certification. Rubber-stamped signatures may not be
used in place of written signatures or initials. The use of rubber block stamps under the
written signature is recommended because it provides a means of identifying the person
making the entry.