c. Professional Staff. Health care providers (doctors and nurses) must record
promptly and correctly all patient observations, treatments, and care provided to the
patient. This data becomes part of the Inpatient Treatment Record.
FOR WHOM PREPARED
a. An Inpatient Treatment Record is prepared for:
(1) Every bed patient (military or civilian) in a hospital, fixed health clinic, or
(2) Each live born infant delivered in one of the above medical treatment
(3) Carded for Record Only (CRO) cases when the patient will not occupy a bed
but an inpatient record must be initiated.
b. An Inpatient Treatment Record is not prepared for:
(1) Stillbirths (delivery of a dead infant).
(2) Patients treated in MTFs supporting combat operations when U.S. Field
Medical Cards are used.
c. When patients are transferred, their ITRs are sent to the patient administrator at
the next medical treatment facility.
Section II. VARIATIONS OF INPATIENT TREATMENT RECORDS
TYPES OF INPATIENT TREATMENT RECORDS
The nature of the case (type of illness or injury) or the length of stay determines
whether a routine Inpatient Treatment Record, an Abbreviated Inpatient Treatment Record,
or a Carded for Record Only Inpatient Treatment Record is initiated for the patient.
ROUTINE INPATIENT RECORD
a. A routine Inpatient Treatment Record is required for patients receiving long-term
care. (If a patient is hospitalized for more than 72 hours, his case is classified as long-term