d. Dating Entries. All entries in the ITR must be dated. Dates should be written in
a day-month-year sequence, and months designated by name--not by number.
e. Corrections to Entries. To correct an entry in the ITR, a single line should be
drawn through the incorrect information. (The crossed-out information should remain
readable.) Then, the new information should be added, dated, and signed, with title, by the
person making the correction.
1-11. IDENTIFICATION OF PATIENT
a. The "Patient Identification" section on each form and report in the ITR must be
completed. Usually, the patient's admitting plate and a mechanical device are used to
imprint this section. At a minimum, the patient identification must include: patient's name;
rank, grade, or status; family member prefix; sponsor's social security number (SSN); and
register number.
b. Two copies of the Inpatient Treatment Record Cover Sheet (ITRCS) are placed
at the front of each ITR. The ITRCS is computer-generated in hospitals and medical
centers with this capability. Regardless of the process, the ITRCS, as well as other forms,
must have complete patient identification.
1-12. ADMISSION HISTORY AND PHYSICAL EXAMINATION
a. History. An admission history must be written within 24 hours of the patient's
admission. SF 504 (see figure 1-5) and SF 505 (see figure 1-6 and figure 1-7) are used
for the history. The history is recorded by a staff physician, a resident, or a physician
assistant (PA). When recorded by a physician assistant, the history must be reviewed by
an attending physician and countersigned.
b. Physical Examination. The ITR must also contain a thorough physical
examination recorded on SF 506 (see figure 1-8). The examination must be current (that
is, it must have been completed within the preceding 24 hours); it must be related to the
illness for which the patient is hospitalized; and the findings must be recorded in specific
terms.
1-13. SF 509 (DOCTOR's PROGRESS NOTES)
a. General. Progress notes chronologically describe the clinical status of the
patient. They must reflect any change in the patient's condition and the results of treatment
and must be recorded by the person giving the treatment or making the observation.
MD0753
1-12
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