(2) Patient Administration Division (PAD). The personnel in PAD must code
and complete the ITRCS in typewritten form. (Both the worksheet and the typewritten copy
of the ITRCS should be filed in the ITR.) Then, forms must be assembled in the order
described in table 1 -1 and fastened into the ITR folder. The record must be reviewed for
accuracy; completeness, including dates and signatures; laboratory reports; X-ray reports;
and other reports, as necessary. If errors are found or if information or signatures are
missing, the record must be sent to the physician or nurse, as appropriate, for correction
and completion. Once the record is complete, the ITR must be filed as described in the
lesson "Terminal Digit Filing" in Subcourse MD0751.
b. Transfer for Further Treatment in Military MTF or Veterans Administration
(VA) MTF. Occasionally, patients are transferred to another uniformed service or VA
medical treatment facility (MTF). When this happens, certain actions on the ITR are
required by the physician and PAD.
(1) Attending physician. The physician completes the worksheet copy of the
ITRCS, dictates or writes up the SF 502 (Narrative Summary), and forwards the ITR to the
PAD.
(2) Patient Administration Division. PAD personnel must complete the ITRCS
in typewritten form; assemble and review the entire record for accuracy and completeness;
make copies of the ITRCS and Narrative Summary; and forward the ITR with the patient to
the next uniformed service or Veteran's Administration MTF. The movement of the patient
must not be delayed for completion of his record. Medical care has first priority;
administrative needs are secondary.
c. Discharge for Movement to Civilian MTF. At times, a patient may be sent to
a civilian hospital for treatment when it is not available at the military MTF. In this case, the
original ITR must remain with the Army MTF since this record is the property of the U.S.
Government. When a patient is sent to a civilian hospital for treatment, these actions must
be taken:
(1) The doctor and PAD personnel process the ITR in the same manner as a
termination for treatment (discussed in paragraph 1-20a).
(2) A copy of the ITR is prepared and sent with the patient to the civilian facility.
(3) The original ITR is retained and filed according to the standard procedure.
d. Retirement of Records for Storage. The rules for retirement of records
depend upon the status of the military treatment facility. AR 40-66 specifies that medical
centers (MEDCENS) are to have five-year inpatient treatment record maintenance. These
medical centers are: Brooke Army Medical Center, Fitzsimons Army Medical Center,
Madigan Army Medical Center, Tripler Army Medical Center, William Beaumont Army
Medical Center, Walter Reed Army Medical Center, Dwight David Eisenhower Army
MD0753
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