FORMS REQUIRED FOR ITRs
a. The forms and reports filed in an Inpatient Treatment Record (ITR) depend on the
nature of the case and the treatment given. All forms and reports needed for a case must
be included in the ITR.
b. DA Form 3647, Inpatient Treatment Record Cover Sheet (ITRCS), is initiated in
the admitting office. When the patient is discharged, the attending physician will complete
the "worksheet" and prepare SF 502, Narrative Summary. He will then send the completed
"worksheet" to the Patient Administration Division (PAD) where the information is keyed
into the computer in final form. Two copies of the Inpatient Treatment Record Cover Sheet
(ITRCS) must be prepared for each hospitalization and included in all ITRs. Details about
the use of the Inpatient Treatment Record Cover Sheet are given in lesson 3 of this
c. The forms used for various types of ITRs are described below:
(1) Routine Inpatient Treatment Record.
(a) *DA Form 3647 (Inpatient Treatment Record Cover Sheet) is placed at
(b) Next, are filed all Standard Forms, such as SF 502 (Clinical
Record-Narrative Summary or OF 275 used to transcribe the narrative summary).
(c) OF 275 (Medical Record Report) is a continuous form used to print
transcription of dictated reports. When OF 275 is used in place of one of the standard
forms, the number of the form it replaces will be marked in the lower left-hand corner and
(d) Then, all DA Forms, such as DA Form 4256 (Doctor's Orders) are filed.
(e) Then, all DD Forms, such as DD Form 741 (Eye Consultation) are filed.
(f) Finally, if there are unnumbered forms, they are filed after the DD forms.
Details about the sequence of forms which make up the ITR are provided later in this
(2) Abbreviated Inpatient Treatment Record.
(a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover
Sheet) are placed at the front of the folder.
(b) SF 539 (Abbreviated Medical Record) is filed next. This form replaces