Custom Search
|
|
SPECIAL PROCEDURES AND THERAPY.- When
patients are seen repeatedly for special procedures or therapy, such as physical and
occupational therapy, renal dialysis, or radiation, note
the therapy on the SF 600 and record interim
progress statements. Initial notes,
interim progress notes, and any
summaries may be recorded on any appropriate
authorized form, but should be referenced on SF 600.
Write a final summary when special
procedures or therapy are ended. This
summary should include the result of
evaluative procedures, the treatment given,
the reaction to treatment, the progress noted, condition
on discharge (when applicable), and any
other pertinent observations.
SICK CALL VISITS.-Whenever a member is evaluated at sick call, an entry will be made on an SF 600 reflecting the complaints or conditions presented, pertinent history, treatment rendered, and disposition. INJURY OR POISONING.-In the event of injury or poisoning, record the duty status of the member at the time of occurrence and the circumstances of occurrence per the guidelines in BUMEDINST 6300.3, Inpatient Data System. LINE-OF-DUTY INQUIRIES.-When a member of the naval service incurs an injury that might result in permanent disability or results in his physical inability to perform duty for a period exceeding 24 hours, an entry should be made concerning line-of-duty misconduct. Such entries should include facts, such as time of injury, date, place, names of persons involved, and the circumstances surrounding the injury. A line-of-duty inquiry is conducted to establish whether the injuries the patient sustained are the result of misconduct on the part of the member or others. For more details on line-of-duty inquiries, see the Manual of the Judge Advocate General (JAGMAN). BINNACLE LIST AND SICK LIST.-When a member's name is placed on the Binnacle List for treatment, make an entry on the SF 600 showing date, diagnosis, and a summary of treatment. When an active duty member is placed on the Sick List, the medical department representative (MDR) should enter information on the SF 600 about the nature of the disease, illness, or injury; pertinent history or circumstances of occurrence; treatment rendered; and disposition. SERIOUSLY ILL/VERY SERIOUSLY ILL (SI/VSI) LIST.-Place personnel whose illness or injuries are severe on the SI/VSI List (as defined in MILPERSMAN 4210100) and make appropriate notification. RESERVIST CHECK-IN ANDCHECK-OUT STATEMENTS.-Naval Reserve personnel who are checking in, or out on orders for annual training (AT), active duty for training (ADT), or inactive duty training travel (IDTT)) should sign the following statements. The statements should be entered on an SF 600 and signed by the reserve member and the MDR. For personnel checking in: (Member's and MDR's signature and date) (Member's and MDR's signature and date) Special SF 600s SPECIAL-HYPERSENSITIVITY SF 600.- Indicate any hypersensitivity to drugs or chemicals on a separate SF 600 (fig. 12-5). The SF 600 will be marked "SPECIAL-HYPERSENSITIVITY" at the bottom of the page. Appropriate entries regarding the hypersensitivity should be made on the SF 601 (Immunization Record), SF 603 (Dental Report), NAVMED 6150/10-19 (HREC jacket), and the NAVMED 6150/20 (Summary of Care). BLOOD GROUPING AND TYPING RECORD.-The Blood Grouping and Typing Record, which is generated at the member's initial entry processing point, is an SF 600 overprint. Information on the Blood Grouping and Typing Record identifies the individual by the appropriate ABOgroup and Rh type (positive or negative). Testing results are documented on the form and the original laboratory request filed with the SF 545, Laboratory Result Display, in the member's HREC. The Blood Grouping and Typing Record may also contain a syphilis screening test and other screening test for the presence of certain diseases. |
||