LESSON 1
INPATIENT TREATMENT RECORDS
Section I. BACKGROUND INFORMATION
1-1.
PURPOSE
a. Medical Record. As explained in Subcourse MD0750, Introduction to Medical
Records and The Patient Administration Division, dated 1998, a medical record is any
military or civilian document that provides information on the evaluation, findings,
diagnosis, and treatment of a patient. Included as medical records are the Inpatient
Treatment Record, the Outpatient Treatment Record, the Health Record, Civilian Employee
Medical Record, and Alcohol and Drug Abuse Prevention and Control Program Outpatient
Medical Records.
b. Inpatient Treatment Record (ITR). The ITR is the record used at a medical
treatment facility (MTF) that has authorized beds for inpatient medical care. This record is
initiated upon the patient's admission to an MTF and is completed when his hospitalization
is terminated. This record is used for all beneficiary categories, military or civilian.
c. Purpose. The purpose of an ITR is to:
(1) Provide a complete medical history on the management (including
observations treatments, and care) of a patient while he is hospitalized.
(2) Communicate with all health care providers who interface with the patient.
(3) Provide medico-legal support for the care provided.
(4) Provide information (as needed) for education and research.
1-2.
FORMS
The DA Form 3444-series (Terminal Digit File Folder) is initiated when an inpatient
treatment record is required (see para 1-4). The same preparation instructions outlined in
Subcourse MD0751, Outpatient Medical Records Branch, dated 1998, apply to the
Inpatient Treatment Record (ITR). All authorized forms are fastened into the DA Form
3444-series file folder. The filing sequence of these forms within the folder is covered later
in this lesson. Figure 1-1 shows a completed DA Form 3444-series used as a file folder
for an Inpatient Treatment Record.
MD0753
1-2
Previous Page
