RIGHT SIDE OF FOLDER
Form Title and Notes
DA Form 3824
DA Form 4221
DA Form 4221
DA Form 4256
DA Form 4677
Therapeutic Documentation Care Plan (Non-Medication
(See AR 40-407).
DA Form 4678
Therapeutic Documentation Care Plan
DA Form 4700
Medical Record - Supplemental Medical Data.
DA Form 5128
Clinical Record - Visual Field Examination.
DD Form 602
Patient Evacuation Tag (See AR 40-40).
DD Form 741
DD Form 749
Clinical Record - Head Injury (for file purpose only).
DD Form 1380
U.S. Field Medical Card.
DA Form 4359-R
Authorization for Psychiatric Service. Treatment (See AR 40-3).
Medical Reports on a stillborn infant. (Filed in the mother's ITR.)
DA Form 2985
Admission and Coding Information.
DA Form 4410-R
Disclosure Accounting Record. To be included when preprinted
DA Form 3444 series folders are not used.
DD Form 2005
Privacy Act Statement - Health Care Records. To be included
when preprinted DA Form 3444 series folders are not used
Table 1-1. Filing sequence for documents in ITR folder (concluded).
1-20. DISPOSITION OF RECORDS
a. Termination of Treatment. When the patient is discharged from the hospital at
the end of treatment, the ITR must be completed before filing.
(1) Attending physician. The attending physician completes the worksheet copy
of the ITRCS. The attending physician dictates the Narrative Summary and makes final
progress notes on SF 509 or SF 539. When this is accomplished, the physician forwards
the ITR to the Patient Administration Division.