Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 93

GENERAL SERVICES ADMINISTRATION

Interagency Committee for Medical Records (ICMR); Automation of

Medical Standard Form 93

AGENCY: General Services Administration.

ACTION: Guideline on automating medical standard forms.

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BACKGROUND: The Interagency Committee on Medical Records (ICMR) are

aware of numerous activities using computer-generated medical forms,

many of which are not mirror images of the genuine paper Standard Form.

With GSA's approval the ICMR eliminated the requirement that every

electronic version of a medical Standard/Optional form be reviewed and

granted an exception. The committee proposes to set data standards and

require that activities developing computer-generated versions adhere

to the required data elements but not necessarily to the image. The

ICMR plans to review medical Standard/Optional forms which are commonly

used and/or commonly computer-generated. We will identify those data

elements which are required, those (if any) which are optional, and the

required format (if necessary). Activities may not add data elements

that would change the meaning of the form. This would require written

approval from the ICMR. Using the process by which overprints are

approved for paper Standard/Optional forms, activities may add other

data elements to those required by the committee. With this decision,

activities at the local or headquarters level should be able to develop

electronic versions which meet the committee's requirements.

SUMMARY: With GSA's approval, the Interagency Committee on Medical

Records (ICMR) eliminated the requirement that every electronic version

of a medical Standard/Optional form be reviewed and granted an

exception. The following data elements must appear on the electronic

version of the following form:

Electronic Elements for SF 93

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Item Placement *

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Text:

Title: Report of Medical History....................................... Top of form.

Note: This information is for official and medically-confidential use Top of form.

only and will not be released to unauthorized persons.

Form ID: Standard Form 93 (Rev. 6-96).................................. Bottom right corner of form.

[[Page 27550]]

I certify that I have reviewed the foregoing information supplies by me Before signature of examinee.

and that it is true and complete to the best of my knowledge. I

authorize any of the doctors, hospitals, or clinics mentioned above to

furnish the Government a complete transcript of my medical record for

purposes of processing my application for this employment or service.

I understand that falsification of information on Government forms is

punishable by fine and/or imprisonment.

Note: Hand to the doctor or nurse, or if mailed mark envelope ``TO BE

OPENED BY MEDICAL OFFICER ONLY''.

Data Entry Fields:

No. of Attached Sheets:

Date of Exam.

Name of Patient (Last, first, middle).

Identification Number.

Grade.

Home Street Address (Street or RFD; City or Town; State; and ZIP Code).

Eamining Facility.

Purpose of Examination.

Statement of Patient's Present Health and Medications Currently Used.

Present Health.

Current Medication.

Regular or Interm.

Allergies (include insect bites/stings and common foods).

Height.

Weight.

Patient's Occupation.

Are you (check one).

Right Handed.

Left Handed.

Past/Current Medical History (response is either Yes, No, or Don't

know).

Household contact with anyone with tuberculosis.

Tuberculosis or positive TB test.

Blood in sputum or when coughing.

Excessive bleeding after injury or dental work.

Suicide attempt or plans.

Sleepwalking.

Wear corrective lenses.

Eye surgery to correct vision.

Lack vision in either eye.

Wear a hearing aid.

Sutter or stammer.

Wear a brace or back support.

Scarlet fever.

Rheumatic fever.

Swollen or painful joints.

Frequent or severe headaches.

Dizziness or fainting spells.

Eye trouble.

Hearing loss.

Recurrent ear infections.

Chronic or frequent colds.

Severe tooth or gum trouble.

Sinusitis.

Hay fever or allergic rhinitis.

Head injury.

Asthma.

Shortness of breath.

Pain or pressure in chest.

Chronic cough.

Palpitation or pounding heart.

Heart trouble.

High or low blood pressure.

Cramps in your legs.

Freuent indigestion.

Stomach, liver or intestinal.

Gall bladder trouble or gallstones.

Jaundice or hepatitis.

Broken bones.

Adverse reaction to medication.

Skin diseases.

Tumor, growth, cyst, cancer.

Hernia.

Hemorrhoids or rectal disease.

Frequent or painful urination.

[[Page 27551]]

Bed wetting since age 12.

Kidney stone or blood in urine.

Sugar or albumin in urine.

Sexually transmitted diseases.

Recent gain or loss of weight.

Eating disorder (anorexia, bulimia, etc.).

Arthritis, Rheumatism, or Bursitis.

Thyroid trouble or goiter.

Bone, joint or other deformity.

Loss of finger or toe.

Painful or ``trick'' shoulder or elbow.

Recurrent back pain or any back injury.

``Trick'' or locked knee.

Foot trouble.

Nerve injury.

Paralysis (including infantile).

Epilepsy or seizure.

Car, train, sea or air sickness.

Frequent trouble sleeping.

Depression or excessive worry.

Loss of memory or amnesia.

Nervous trouble of any sort.

Periods of unconsciousness.

Parent/sibling with diabetes, cancer, stroke or heart disease.

X-ray or other radiation therapy.

Chemotheraphy.

Asbestos or toxic chemical exposure.

Plate, pin or rod in any bone.

Easy fatigability.

Been told to cut down or criticized for alcohol use.

Use illegal substances.

Use tobacco.

Females Only--Treated for a female disorder--Yes (Check box).

Females Only--Treated for a female disorder--No (Check box).

Females Only--Treated for a female disorder--Don't know (Check box).

Females Only--Change in menstrual pattern--Yes (Check box).

Females Only--Change in menstrual pattern--No (Check box).

Females Only--Change in menstrual pattern--Don't know (Check box).

Females Only--Date of Last Menstrual Period.

Females Only--Date of Last Pap Smear.

Females Only--Date of Last Mammogram.

Have you been refused employment or been unable to hold a job or stay

in school because of: Sensitivity to chemicals, dust, sunlight, etc.--

Yes (Check box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Sensitivity to chemicals, dust, sunlight, etc.--

No (Check box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to perform certain motions--Yes (Check

box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to perform certain motions--No (Check

box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to assume certain positions--Yes

(Check box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to assume certain positions--No (Check

box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to assume certain positions--Other

medical reasons (If yes, give reasons.)--Yes (Check box).

Have you been refused employment or been unable to hold a job or stay

in school because of: Inability to assume certain positions--Other

medical reasons (If yes, give reasons.)--No (Check box).

Have you ever been treated for a mental condition? (If yes, specify

when, where, and give details)--Yes (Check box).

Have you ever been treated for a mental condition? (If yes, specify

when, where, and give details)--No (Check box).

Have you ever been denied life insurance? (If yes, state reason and

give details)--Yes (Check box).

Have you ever been denied life insurance? (If yes, state reason and

give details)--No (Check box).

Have you had, or have you been advised to have, any operation? (If yes,

describe and give age at which occurred.)--Yes (Check box).

Have you had, or have you been advised to have, any operation. (If yes,

describe and give age at which occurred.)--No (Check box).

Have you ever been a patient in any type of hospital? (If yes, specify

when, where, why, and name of doctor and complete address of

hospital)--Yes (Check box).

Have you ever been a patient in any type of hospital? (If yes, specify

when, where, why, and name of doctor and complete address of

hospital)--No (Check box).

[[Page 27552]]

Have you consulted or been treated by clinics, physicians, healers, or

other practitioners within the past 5 years for other than minor

illnesses? (If yes, give complete address of doctor, hospital, clinic,

and details)--Yes (Check box).

Have you consulted or been treated by clinics, physicians, healers, or

other practitioners within the past 5 years for other than minor

illnesses? (If yes, give complete address of doctor, hospital, clinic,

and give details)--No (Check box).

Have you ever been rejected for military service because of physical,

mental, or other reasons? (If yes, give date and reason for

rejection)--Yes (Check box).

Have you ever been rejected for military service because of physical,

mental, or other reasons? (If yes, give date and reason for

rejection)--No (Check box).

Have you ever been discharged from military service because of

physical, mental, or other reasons? (If yes, give date, reason, and

type of discharge; whether honorable, other than honorable, for

unfitness or unsuitability.)--Yes (Check box).

Have you ever been discharged from military service because of

physical, mental, or other reasons? (If yes, give date, reason, and

type of discharge; whether honorable, other than honorable, for

unfitness or unsuitability.)--No (Check box).

Have you ever received, is there pending or have you ever applied for

pension or compensation for existing disability? (If yes, specify what

kind, granted by whom, and what amount, when.)--Yes (Check box).

Have you ever received, is there pending or have you ever applied for

pension or compensation for existing disability? (If yes, specify what

kind, granted by whom, and what amount, when.)--No (Check box).

Have you ever been arrested or convicted of a crime, other than minor

traffic violations (If yes, provide details.)--Yes (Check box).

Have you ever been arrested or convicted of a crime, other than minor

traffic violations (If yes, provide details.)--No (Check box).

Have you ever been diagnosed with a learning disability? (If yes, give

type, where, and how diagnosed.)--Yes (Check box).

Have you ever been diagnosed with a learning disability? (If yes, give

type, where, and how diagnosed.)--No (Check box).

List All Immunizations Received.

Typed or Printed Name of Examinee.

Signature of Examinee.

Date of Signature.

Physician's Summary and Elaboration of All Pertinent Data. (Physician

shall comment on all positive answers in Items 7 through 11.

Physicians may develop by interview any additional medical history

deemed important, and record any significant findings here.)

Typed or Printed Name of Physician or Examiner.

Signature of Physician or Examiner.

Date of Signature.

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* If no placement indicated, items can appear anywhere on the form.

FOR FURTHER INFORMATION CONTACT: CDR Steven S. Kerrick, USN National

Naval Medical Center, Department of Ophthalmology, Bethesda, MD 20889-

5000 or E-Mail at StevenK[email protected].

Dated: May 12, 1999.

Steven S. Kerrick,

Chairperson, Interagency Committee on Medical Records.

[FR Doc. 99-12704 Filed 5-19-99; 8:45 am]

BILLING CODE 6820-34-M