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US Army Medical Course MD0753-101 Book1 - Medical Records Administration Branch

US Army Medical Course MD0753-101 Book1 - Medical Records Administration Branch

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U. S.

ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL FORT SAM HOUSTON, TEXAS 78234

MD0753
MEDICAL RECORDS ADMINISTRATION BRANCH I (BOOK 1 OF 2)

EDITION 101

DEVELOPMENT This subcourse reflects the current thought of the Academy of Health Sciences and conforms to printed Department of the Army doctrine as closely as currently possible. Development and progress render such doctrine continuously subject to change. When used in this publication, words such as "he," "him," "his," and "men" are intended to include both the masculine and feminine genders, unless specifically stated otherwise or when obvious in context. The contractor responsible for the development of this subcourse was Advanced Development Group. The instructional systems specialist responsible for overseeing development was Mr. Richard Smart, DSN 421-9931; commercial (210) 295-9931, and the subject matter expert responsible for content accuracy was SFC Mark Minter, DSN 4710944; commercial (210) 221-0944, COMMANDER, U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL, DEPARTMENT OF HEALTHCARE OPERATIONS, ATTN: MCCS-HHP, 3151 SCOTT ROAD, FORT SAM HOUSTON, TX 78234-6100. ADMINISTRATION Students who desire credit hours for this correspondence subcourse must meet eligibility requirements and must enroll through the Nonresident Instruction Branch of the U.S. Army Medical Department Center and School (AMEDDC&S). Application for enrollment should be made at the Internet website: http://www.atrrs.army.mil. You can access the course catalog in the upper right corner. Enter School Code 555 for medical correspondence courses. Copy down the course number and title. To apply for enrollment, return to the main ATRRS screen and scroll down the right side for ATRRS Channels. Click on SELF DEVELOPMENT to open the application and then follow the on screen instructions. In general, eligible personnel include enlisted personnel of all components of the U.S. Army who hold an AMEDD MOS or MOS 18D. Officer personnel, members of other branches of the Armed Forces, and civilian employees will be considered eligible based upon their AOC, NEC, AFSC or Job Series which will verify job relevance. Applicants who wish to be considered for a waiver should submit justification to the Nonresident Instruction Branch at e-mail address: accp@amedd.army.mil. For comments or questions regarding enrollment, student records, or shipments, contact the Nonresident Instruction Branch at DSN 471-5877, commercial (210) 221-5877, toll-free 1-800-344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail accp@amedd.army.mil, or write to: NONRESIDENT INSTRUCTION BRANCH AMEDDC&S ATTN: MCCS-HSN 2105 11TH STREET SUITE 4191 FORT SAM HOUSTON TX 78234-5064

TABLE OF CONTENTS Lesson INTRODUCTION ............................................................................ 1 INPATIENT TREATMENT RECORDS........................................ 1-1--1-20 Section I. Section II. Section III. Section IV. Background Information..................................... Variations of Inpatient Treatment Records ...... Essential Elements............................................. Filing and Disposition ........................................ 1-1--1-4 1-5--1-9 1-10--1-17 1-18--1-20 Paragraphs Page v 1-1 1-2 1-4 1-7 1-30 1-37 2-1 2-2 2-6 2-12 2-22 3-1 3-2 3-5 3-17 4-1 4-2 4-9

Exercises ..................................................................................... 2 DIAGNOSTIC AND OPERATIVE CODING................................ 2-1--2-19 Section I. Section II. Section III. General ................................................................ 2-1--2-6 Conventions and Terminology........................... 2-7--2-12 Use of ICD-9-CM................................................ 2-13--2-19

Exercises ..................................................................................... 3 INPATIENT TREATMENT RECORD COVER SHEET............. 3-1--3-6 Section I. Section II. General ................................................................ 3-1--3-3 Completion of the Inpatient Treatment Record Cover Sheet........................................... 3-4--3-6

Exercises ..................................................................................... 4 INDIVIDUAL PATIENT DATA SYSTEM...................................... 4-1--4-109 Section I. Section II. Section III. Section IV. General ................................................................ Coding of DA Form 2985 .................................. Coding of the A&C Form From the U.S. Field Medical Card (FMC)................................. Transmittal Procedures and Data Access....... 4-1--4-5 4-6--4-84

4-85--4-107 4-76 4-108--4-109 4-83 4-85

Exercises ..................................................................................... * Appendices under separate cover (Book 2 of 2)

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LIST OF FIGURES Figure 1-1 1-2 1-3 1-4 1-5 1-6 1-7 1-8 1-9 1-10 1-11 1-12 1-13 1-14 Completed DA Form 3444-6 used as an Inpatient Treatment Record.............. DA Form 3647 (Inpatient Treatment Record Cover Sheet) ................................ OF 275 (Medical Record Report) .......................................................................... SF 539 (Abbreviated Medical Record)................................................................. SF 504 (History - Part 1) ........................................................................................ SF 505 (History - Part 2)......................................................................................... SF 505 (History - Part 3)......................................................................................... SF 506 (Physical Examination).............................................................................. SF Form 509 (Doctor's Progress Notes).............................................................. DA Form 4256 (Doctor's Orders) .......................................................................... SF 510 (Nursing Notes) .......................................................................................... SF 516 (Operation Report)..................................................................................... SF 515 (Tissue Examination)................................................................................. SF 522 (Request for Administration of Anesthesia and for Performance of Operations and Other Procedures) .................................... 1-15 SF 517 (Anesthesia Form)..................................................................................... 1-16 SF 502 (Narrative Summary) ................................................................................. 2-1 Volume 1, Table of Contents (Continued)............................................................. 2-2 ITRCS (handwritten and typed copies).................................................................. 2-3 Example of alphabetical arrangement of Volume 2, ICD-9-CM (showing indentation of main terms and modifiers)............................................................ 2-4 Volume 3, Example of alphabetic arrangement of Vol. 2, ICD-9-CM................ 3-1 DA Form 3647 (Inpatient Treatment Record Cover Sheet for typed entries) .................................................................................................................... 3-2 DA Form 3647 (Inpatient Treatment Record Cover Sheet for computer generated entries) ................................................................................................. 3-3 Relationship of DA Form 2985 and DA Form 3647............................................ 3-4 DA Form 3647 for Exercise 17.............................................................................. 3-5 DA Form 3647 for Exercise 18.............................................................................. 3-6 DA Form 3647 for Exercise 19.............................................................................. 3-7 DA Form 3647 for Exercise 20.............................................................................. 3-8 DA Form 3647 for Exercise 17.............................................................................. 3-9 DA Form 3647 for Exercise 18.............................................................................. 3-10 DA Form 3647 for Exercise 19.............................................................................. 3-11 DA Form 3647, Solution for Exercise 20 .............................................................. Page 1-3 1-8 1-9 1-10 1-14 1-15 1-16 1-17 1-18 1-21 1-22 1-24 1-25 1-26 1-27 1-29 2-4 2-13 2-16 2-19 3-7 3-8 3-9 3-21 3-22 3-23 3-24 3-27 3-28 3-29 3-30

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LIST OF FIGURES Figure 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 4-10 4-11 4-12 4-13 4-14 4-15 4-16 4-17 4-18 DA Form 2985 (Admission and Coding Information) .......................................... DA Form 3647 (Inpatient Treatment Record Cover Sheet-typed) ..................... Julian Date Calendar (Perpetual) .......................................................................... DD Form 1380 (U.S. Field Medical Card)............................................................ DA Form 3647, Inpatient Treatment Record Cover Sheet.................................. DA Form 2985 for Exercise 21 (continued).......................................................... DA Form 2985 for Exercise 21 (continued).......................................................... DA Form 2985 for Exercise 21 (concluded)......................................................... DA Form 3647, Inpatient Treatment Record Cover Sheet.................................. DA Form 2985 for Exercise 22 (continued).......................................................... DA Form 2985 for Exercise 22 (continued).......................................................... DA Form 2985 for Exercise 22 (concluded)......................................................... DA Form 2985 for Exercise 21 (continued).......................................................... DA Form 2985 for Exercise 21 (continued).......................................................... DA Form 2985 for Exercise 21 (concluded)......................................................... DA Form 2985 for Exercise 22 (continued).......................................................... DA Form 2985 for Exercise 22 (continued).......................................................... DA Form 2985 for Exercise 22 (continued).......................................................... Page 4-5 4-8 4-70 4-78 4-89 4-90 4-91 4-92 4-94 4-95 4-96 4-97 4-100 4-101 4-102 4-103 4-104 4-105

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LIST OF TABLES Table Page

1-1 Filing sequence for documents in ITR folder............................................................1-31 3-1 Abbreviations used on the ITRCS.............................................................................3-4 4-1 4-2 4-3 4-4 4-5 4-6 4-7 4-8 4-9 4-10 4-11 4-12 4-13 4-14 4-15 4-16 4-17 4-18 4-19 4-20 4-21 4-22 Medical treatment facility (MTF) codes .................................................................. 4-10 State location codes...................................................................................................4-11 Grade codes ...............................................................................................................4-13 Sex codes....................................................................................................................4-15 Age codes ...................................................................................................................4-17 Race codes .................................................................................................................4-17 Ethnic background codes ..........................................................................................4-18 Religion abbreviations ...............................................................................................4-19 Length of service codes.............................................................................................4-21 Family member prefix (FMP) codes.........................................................................4-22 Marital status codes ...................................................................................................4-24 Categories of U.S. Uniformed Services Personnel................................................4-26 Department/type of beneficiary codes .....................................................................4-27 Trauma codes .............................................................................................................4-35 Source of admission codes.......................................................................................4-37 Disposition type codes ..............................................................................................4-39 First position MTF codes...........................................................................................4-42 Medical Expense and Performance Reporting System (MEPRS) clinic service codes............................................................................................................4-44 Underlying cause of death/separation codes ..........................................................4-53 Place of occurrence of injury third-digit codes ........................................................4-55 Place of treatment codes...........................................................................................4-57 Surgical procedures place of performance codes..................................................4-59

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CORRESPONDENCE COURSE OF THE ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL SUBCOURSE MD0753 MEDICAL RECORDS ADMINISTRATION BRANCH I INTRODUCTION The Inpatient Treatment Record (ITR) is prepared for all patients admitted to a medical treatment facility (MTF). This ITR is used to provide a record of patient care and treatment; to plan patient care; and to serve as a communication device between the physician and other health care professionals. The diagnosis and medical procedures performed on an inpatient are numerically coded for input into the Individual Patient Data System (IPDS), a computer system for the collection of statistical information. Through this system, statistical information is obtained for planning, managing, and evaluating the Army Medical Department medical care system for medical and epidemiological research. The IPDS also is a source of data for the Medical Command, Office of The Surgeon General, and other relevant requestors; and for management reports for the hospital commander and his staff. This subcourse will explain the procedure for maintaining and controlling Inpatient Treatment Records; coding diagnosis and procedures on the Inpatient Treatment Record Cover Sheet (ITRCS); preparing the coding information forms; and for disposing of the ITRs. This subcourse will familiarize you with the tasks performed in the Medical Records Administration Branch and will enhance your skill and proficiency in performing these tasks. Subcourse Components: Subcourse MD0753 consists of four lessons and an examination (Book 1 of 2), and appendices under separate cover (Book 2 of 2). The lessons are: Lesson 1, Inpatient Treatment Records. Lesson 2, Diagnostic and Operative Coding. Lesson 3, Inpatient Treatment Record Cover Sheet. Lesson 4, Individual Patient Data System. Credit Awarded: You will be awarded 20 credit hours for the successful completion of this subcourse. Lesson Materials Furnished: Materials provided include this booklet, an examination answer sheet, and an envelope. (The examination is included in this booklet.) No other text is required. You must furnish a #2 pencil.

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The exercises and solutions for all exercises are also contained in this booklet. Answer sheets are not provided for the exercises. You are encouraged to complete the subcourse lesson by lesson. Procedures for Subcourse Completion: You will submit your examination answer sheet to the AMEDDC&S for grading. When you have completed the examination exercises to your satisfaction, fill out the enclosed examination answer sheet and mail it to the AMEDDC&S in the envelope provided. You will be notified by return mail of the results. Include your social security number on all correspondence sent to the AMEDDC&S. The grade you make on the examination will be your rating for the subcourse. Study Suggestions: We suggest that you follow these study procedures: --Read and study each lesson assignment carefully. --Complete the lesson exercises for the first lesson, marking your answers in this booklet. Refer to the text material as necessary. --When you have completed the exercises to your satisfaction, compare your answers with the solution sheet located at the end of the lesson. Check the references for your incorrect answers. --After you have successfully completed one lesson, go on to the next and repeat the above procedures. --When you feel confident that you have mastered the study materials, complete the examination. We suggest that you complete the examination by first marking each answer in this booklet. When you have responded to each item to your satisfaction, transfer your responses to the examination answer sheet and mail it to the AMEDDC&S for grading. Student Comment Sheet: A Student Comment Sheet is located at the back of this booklet. It is to be returned with your examination answer sheet. As you study the subcourse, you may wish to make suggestions or comments which will help us to improve the quality of the subcourse.

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LESSON ASSIGNMENT LESSON 1 LESSON ASSIGNMENT LESSON OBJECTIVES Inpatient Treatment Records. Paragraphs 1-1 through 1-20. After completing this lesson, you should be able to: 1-1. Identify the functions of the Inpatient Treatment Record. 1-2. List the essential elements of the Inpatient Treatment Record. 1-3. Identify the correct sequence of forms filed in the Inpatient Treatment Record. 1-4. Identify the variations of the Inpatient treatment Record. 1-5. Identify the disposition of Inpatient Treatment Records. SUGGESTION After reading and studying the assignment, complete the exercises of this lesson. These exercises will help you to achieve the lesson objectives.

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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.

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Figure 1-1. Completed DA Form 3444-6 used as a file folder for an Inpatient Treatment Record.

1-3.

RESPONSIBILITIES

a. MTF Commander. The commander of the medical treatment facility (MTF) is the official custodian of the medical records (including the ITR) at the facility. Each MTF commander is responsible for ensuring that adequate and timely Inpatient Treatment Records are prepared for each patient who is required to have one. b. Chief, Patient Administration Division (PAD). The Chief, PAD acts for the commander in matters of handling ITRs and is responsible for keeping the professional staff informed on the requirements for ITRs.

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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. 1-4. 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 convalescent center. (2) Each live born infant delivered in one of the above medical treatment facilities. (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

1-5.

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. 1-6. 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 care.)

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b. A routine Inpatient Treatment Record is required if a patient has a serious illness, such as a heart attack or pneumonia. c. A routine Inpatient Treatment Record is also required for a patient having major surgery. d. Often, more than one of these criteria may be present. Major surgery generally requires more than 72 hours of care. A serious illness may also require more than 72 hours of care, and a serious illness may also require major surgery. 1-7. ABBREVIATED MEDICAL RECORD

a. SF 539 (Abbreviated Medical Record) may be used for cases of a minor nature that require no more than 72 hours' hospitalization. It may be used for accident cases held for observation, removal of superficial growths, or application of plaster casts. b. If general anesthesia is given, the surgical process must be localized and should not entail a systemic invasion. SF 539 may be used for cases in which general anesthesia is given only if the patient has no organic, physiologic, biochemical, or psychiatric disturbance. c. When military personnel are hospitalized for uncomplicated conditions not usually requiring hospitalization for civilians, such as measles or upper respiratory infections, SF 539 will be used. If the hospital stay exceeds 72 hours, the reason for the extended stay will be fully recorded in the progress notes and a narrative summary must be prepared. 1-8. CARDED FOR RECORD ONLY (CRO)

A case is carded for record only when a patient is not admitted to the hospital but the preparation of a DA Form 3647 (Inpatient Treatment Record Cover Sheet) and the assignment of a register number are required. Examples of CRO cases are: a. Patients who are dead upon arrival (DOA) at the medical treatment facility. b. Medical board examinations performed in an outpatient facility. c. Certain other cases considered by the MTF to have medical, legal, or other significance, such as rape, assault, and driving while intoxicated (DWI). The Medical Records Committee establishes guidelines for these cases.

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1-9.

FORMS REQUIRED FOR ITRs

a. The forms and reports filed in an Inpatient Treatment Record (ITR) depend on the nature of the case and the treatment given. All forms and reports needed for a case must be included in the ITR. b. DA Form 3647, Inpatient Treatment Record Cover Sheet (ITRCS), is initiated in the admitting office. When the patient is discharged, the attending physician will complete the "worksheet" and prepare SF 502, Narrative Summary. He will then send the completed "worksheet" to the Patient Administration Division (PAD) where the information is keyed into the computer in final form. Two copies of the Inpatient Treatment Record Cover Sheet (ITRCS) must be prepared for each hospitalization and included in all ITRs. Details about the use of the Inpatient Treatment Record Cover Sheet are given in lesson 3 of this subcourse. c. The forms used for various types of ITRs are described below: (1) Routine Inpatient Treatment Record. (a) *DA Form 3647 (Inpatient Treatment Record Cover Sheet) is placed at the front of the folder. (See figure 1-2.) (b) Next, are filed all Standard Forms, such as SF 502 (Clinical Record-Narrative Summary or OF 275 used to transcribe the narrative summary). (c) OF 275 (Medical Record Report) is a continuous form used to print transcription of dictated reports. When OF 275 is used in place of one of the standard forms, the number of the form it replaces will be marked in the lower left-hand corner and OF 275 will be filed as if it were the form it replaces. (See figure 1-3.) (d) Then, all DA Forms, such as DA Form 4256 (Doctor's Orders) are filed. (e) Then, all DD Forms, such as DD Form 741 (Eye Consultation) are filed. (f) Finally, if there are unnumbered forms, they are filed after the DD forms. Details about the sequence of forms which make up the ITR are provided later in this lesson. (2) Abbreviated Inpatient Treatment Record. (a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover Sheet) are placed at the front of the folder. (b) SF 539 (Abbreviated Medical Record) is filed next. This form replaces several other forms used in the routine ITR. (See figure 1-4.)

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(3) Carded for record only (CRO). (a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover Sheet) are placed at the front of the folder. (b) Then, other forms as applicable are filed (for example, a copy of the death certificate for a DOA case). * In facilities using the Composite Health Care System (CHCS) or Automated Quality of Care Evaluation Support System (AQCESS), an automated version of DA Form 3647 will be used. The worksheet copy will not be provided.

Section III. ESSENTIAL ELEMENTS

1-10. GENERAL a. Content. Entries are made in a medical record by the health care provider observing, treating, or caring for the patient. Entries on the Inpatient Treatment Record Cover Sheet (ITR) or on any medical form provide a useful record for continued and future care; therefore, all entries must be relevant to actual observation and treatment of the patient, and the record must be current. b. Legibility. All entries in the ITR must be legible. They should be in typewritten form, when possible. When hand-written, entries must be made in permanent black or blue-black ink; rubber stamps may be used only for standardized entries. Certain forms, such as radiology, pathology, and operative reports, and the narrative summary, must be in typewritten form. These are usually dictated and transcribed onto Optional Form 275 (Medical Record Report). c. Signatures. All entries in the ITR must be signed; later entries on the same page by the same person must be signed or initialed. A military member must add grade and corps; a civilian must add title or certification. Rubber-stamped signatures may not be used in place of written signatures or initials. The use of rubber block stamps under the written signature is recommended because it provides a means of identifying the person making the entry.

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Figure 1-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet).

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Figure 1-3. OF 275 (Medical Record Report).

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Figure 1-4. SF 539 (Abbreviated Medical Record) (continued).

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Figure 1-4. SF 539 (Abbreviated Medical Record) (concluded).

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d. Dating Entries. All entries in the ITR must be dated. Dates should be written in a day-month-year sequence, and months designated by name--not by number. e. Corrections to Entries. To correct an entry in the ITR, a single line should be drawn through the incorrect information. (The crossed-out information should remain readable.) Then, the new information should be added, dated, and signed, with title, by the person making the correction. 1-11. IDENTIFICATION OF PATIENT a. The "Patient Identification" section on each form and report in the ITR must be completed. Usually, the patient's admitting plate and a mechanical device are used to imprint this section. At a minimum, the patient identification must include: patient's name; rank, grade, or status; family member prefix; sponsor's social security number (SSN); and register number. b. Two copies of the Inpatient Treatment Record Cover Sheet (ITRCS) are placed at the front of each ITR. The ITRCS is computer-generated in hospitals and medical centers with this capability. Regardless of the process, the ITRCS, as well as other forms, must have complete patient identification. 1-12. ADMISSION HISTORY AND PHYSICAL EXAMINATION a. History. An admission history must be written within 24 hours of the patient's admission. SF 504 (see figure 1-5) and SF 505 (see figure 1-6 and figure 1-7) are used for the history. The history is recorded by a staff physician, a resident, or a physician assistant (PA). When recorded by a physician assistant, the history must be reviewed by an attending physician and countersigned. b. Physical Examination. The ITR must also contain a thorough physical examination recorded on SF 506 (see figure 1-8). The examination must be current (that is, it must have been completed within the preceding 24 hours); it must be related to the illness for which the patient is hospitalized; and the findings must be recorded in specific terms. 1-13. SF 509 (DOCTOR's PROGRESS NOTES) a. General. Progress notes chronologically describe the clinical status of the patient. They must reflect any change in the patient's condition and the results of treatment and must be recorded by the person giving the treatment or making the observation.

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b. Progress Notes by Physician. The physicians' notes are documented on SF 509 (see figure 1-9). They provide an analysis of the patient's clinical course and outline the rationale for specific medical decisions. Physicians' notes begin with an admission note, continue with notes during hospitalization, and conclude with a note on discharge or death. (1) The admission note should briefly record the clinical circumstances that brought the patient to the hospital, summarize the proposed diagnostic workup, and suggest the type of therapeutic management. For emergency patients admitted, SF 558 (Emergency Care and Treatment) may be used as the admission note and placed in the ITR. (2) For surgical patients, the admission note may serve as the preoperative note. In addition to giving the information described in paragraph 1-13b(1), these notes must justify the surgery and state the procedure proposed. (3) The physician or nurse anesthetist's preanesthesia note is recorded on SF 509 or SF 517 (Anesthesia Form), as appropriate. It should explain the choice of anesthesia for the proposed procedure. The postanesthesia note must be made after the patient has left the recovery area and must record the presence or absence of anesthesia-related complications. (4) For the postoperative patient, progress notes should record the condition of the surgical wound, any indication of infection, and the removal of sutures and drains. It should also record examinations of chest and legs until the patient is ambulatory (walking) and afebrile (without fever). It also should record the use of casts or splints, and any other pertinent data.

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Figure 1-5. SF 504 (History - Part 1).

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Figure 1-6. SF 505 (History - Part 2).

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Figure 1-7. SF 505 (History - Part 3).

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Figure 1-8. SF 506 (Physical Examination).

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Figure 1-9. SF 509 (Doctor's Progress Notes).

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(5) The final progress note should record the patient's general condition upon discharge and the final diagnosis. In addition, it should prescribe post discharge care including activity permitted, diet, medications, dressings, and clinic and date for follow-up care. (6) In hospital death cases, the final note should describe the terminal circumstances, findings, and final diagnosis and should state whether or not an autopsy was performed. (7) The frequency of progress notes depends on the condition of the patient. During the acute phase of the illness, the progress notes should be written every day or even every few hours (very seriously ill/seriously ill patients, at least once a day or more often). For surgical patients, there must be a daily note for at least the first four postoperative days. For convalescent patients and fracture patients with no complications, notes are not needed as often as for patients receiving active treatment. In no case should more than seven days pass without a progress note. 1-14. DOCTOR'S ORDERS AND NURSING NOTES a. Use of DA Form 4256. DA Form 4256 (Doctor's Order) is used to convey the actions the doctor wants for the patient. This form is a three-copy, carbonless form. The original copy (white) remains with the patient's permanent record. The second copy (pink) is sent to the pharmacy, where it is kept until the patient is discharged. The ward copy (yellow) is used to give orders to the nursing staff. Figure 1-10 shows a DA Form 4256 with the doctor's order entered. (1) Preparation. All entries are made with a ballpoint pen using blue-black or black ink. The patient identification must be completed in each section using the admitting plate. (2) Method of writing orders. More than one order may be written in each section of the form but not more than one may be written on a single line. The prescriber must record the date and time each order is written. Each order must be accounted for separately. All orders must be dated and signed by the doctor. (3) Method of accounting for orders. Actions taken to comply with written orders will be accounted for in the far right column of the form entitled "List Time Order Noted and Sign" column. The nurse or clerk noting the order must list the time orders are noted and sign or initial his entry. When two or more orders are noted, the nurse may enclose the orders in a brace, list the time orders noted, and sign or initial his entry.

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(4) Use of orders. Every action taken for the patient must be ordered by the doctor. The doctor uses DA Form 4256 to order laboratory work, medication, diet, therapy, and so forth. The nurse, technician, or clerk who is responsible must take note of the orders, enter the time, and either sign or initial in the "List Time Order Noted and Sign" column of this form. b. Progress Notes by Nurses. The nurses responsible for the nursing care given to a patient are required to document this care. (1) Nurses' notes must chronologically describe the nursing care provided on SF 510 (Clinical Record--Nursing Notes). (See figure 1-11.) (2) SF 510 is designed so that the nurse will record the date and time of the observation. Nurses' observations should include: a description of the patient's condition; his vital signs; medication administered; treatment provided (when indicated), and any other pertinent information reflecting the condition of the patient. Each note must be signed by the nurse, giving rank and corps (if a military nurse) or rank and title (if a civilian nurse). When the nurse notes an order by the doctor and carries out the order, the nurse must enter the action on SF 510, including time, action taken, and signature. For example, if the doctor's order states "Demerol 100 mg IM q 4 hr PRN," the nurse should enter on the nursing notes "2100, Demerol 100 mg given IM for abdominal pain," and sign the entry, including rank and corps. The importance of this cannot be overemphasized because if the nurse fails to enter this data on the nursing notes, no one would know that the patient had received the medication and another nurse may administer the medication again, causing an overdose. A drug overdose could compound the patient's illness or result in death.

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Figure 1-10. DA Form 4256 (Doctor's Orders).

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Figure 1-11. SF 510 (Nursing Notes).

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1-15. DIAGNOSTIC TEST RESULTS (REPORTS) When a patient is admitted to the hospital, the physician must enter the proposed diagnostic workup in the Doctor's Progress Notes. The physician orders these tests on DA Form 4256. The nurse must note the physician's orders for diagnostic tests and enter the time the patient is sent for the tests in the Nursing Notes. The most common diagnostic tests include: blood analysis, urinalysis, radiology (X-rays), and electrocardiogram (EKG). The results of these diagnostic tests must be sent back to the ward for inclusion in the patient's ITR; the doctor may annotate the results in the Doctor's Progress Notes. 1-16. SPECIAL REQUIREMENTS If the patient is a surgical or obstetrical patient, additional forms and reports are required. a. Surgery or Special Procedures. The forms required for surgery or special procedures are: (1) SF 516 (Operation Report). (See figure 1-12.) This report describes the operation, including the operation performed, the types of sutures used, gross findings, and other relevant data. (2) SF 515 (Tissue Examination). (See figure 1-13.) Any time tissue is cut, a pathological report is required. This form is used to describe the findings of the pathologist. (3) SF 522 (Request for Administration of Anesthesia and for Performance of Operations and Other Procedures). (See figure 1-14.) This form is used as an authorization or consent form. The patient must sign it to authorize surgery, and the physician must sign it to indicate that he has counseled the patient about the proposed procedure. (4) SF 517 (Anesthesia Form). (See figure 1-15.) This form is used to describe the administration of anesthesia and to provide a preanesthetic summary. b. Obstetrical and Newborn. (1) Two forms are required for the mother when delivering a baby. They are SF 533 (Prenatal Record) and SF 534 (Labor Record). (2) A newborn baby must have a birth certificate. The birth certificate is a local form established by the state where the child is born.

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Figure 1-12. SF 516 (Operation Report).

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Figure 1-13. SF 515 (Tissue Examination).

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Figure 1-14. SF 522 (Request for Administration of Anesthesia and for Performance of Operations and Other Procedures).

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Figure 1-15. SF 517 (Anesthesia Form).

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1-17. CONCLUSIONS. When the patient is dispositioned, certain forms must be prepared for inclusion in the Inpatient Treatment Record. They are the: a. SF 502 (Narrative Summary (NS)). (See figure 1-16.) The Narrative Summary should be dictated promptly upon disposition of the patient. It is then transcribed on SF 502 (Narrative Summary). The NS should be concise but must include (in narrative form) the following information: (1) The reason for hospitalization, including a brief clinical statement of the chief complaint and history of the present illness. (2) All significant findings. (3) All procedures performed and treatment given, including patient's response, complications, and consultations. (4) The condition of the patient upon transfer or discharge. (5) The discharge instructions given to the patient or his family, such as physical activity permitted, medication, diet, and follow-up care. (6) All relevant diagnoses made up to the time of discharge or transfer. b. A discharge note must be entered on SF 509, Doctor's Progress Notes. c. In an Abbreviated ITR, a discharge note on SF 509 or SF 539 is all that is required.

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Figure 1-16. SF 502 (Narrative Summary).

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Section IV. FILING AND DISPOSITION

1-18. FUNCTIONS OF RECORDS a. Inpatient Treatment Records (ITRs) must provide a written record of the care and treatment given each patient while hospitalized and must comply with Army regulations and with standards established by the Joint Commission on Accreditation of Hospital Organizations (JCAHO). b. Medical records provide a measure of the quality of care. They are also the source of documentation for care. c. Medical records are legal documents. The physician is both legally and morally responsible for the content of the ITR. The Patient Administration Division has responsibilities toward these ITRs as well. Ultimate responsibility for ITRs rests with the MTF Commander. 1-19. SEQUENCE OF FORMS a. General. AR 40-66 defines the sequence in which the medical forms are filed in the ITR folder (DA Form 3444-series). Table 1-1 explains the filing sequence for the left and right sides of the folder. b. Sequence. The left side of the folder should contain out-of-the-ordinary forms, such as third party liability notification, very seriously ill/seriously ill reports, and medical board proceeding. The right side of the ITR folder should contain the more commonly used forms resulting from hospitalization. Two copies of DA Form 3647 (ITRCS) should be first in order on the right side; next standard forms (SFs); then, other DA forms; and finally, DD forms. When more than one copy of a form is used, the forms should be filed chronologically-- latest date forward.

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LEFT SIDE OF FODER Form Number DA Form 5571 DA Form 3947 DA Form 3349 DA Form 3894 DA Form 2631-R DA Form 2984 DA Form 4876-R DA Form 5006-R SF 544 DA Form 5009-R Form Title and Notes Master Problem List. (Filing in ITR is optional) Medical Evaluation Board Proceedings. (See AR 40-3). Physical Profile. (See AR-501). Hospital Report of Death. (See AR 40-2). Medical Care - Third Party Liability Notification. (See AR 40-16). Very Seriously Ill/Seriously Ill/Special Category Patient Report. (See AR 40-2). Request and Release of Medical Information to Communications Media. Medical Record - Authorization for Disclosure of Information. Clinical Record - Statement of Patient's Treatment Medical Record - Release Against Medical Advice. RIGHT SIDE OF FOLDER Form Number DA Form 4515 DA Form 3647 SF 502 SF 503 SF 539 SF 504 SF 505 SF 506 SF 535 SF 509 SF 558 DA Form 3888 DA Form 3888-1 SF 510 SF 511 SF 512 Form Title and Notes Personnel Reliability Program Record Identifier. (See AR 50-5). Inpatient Treatment Record Cover Sheet.(all versions). Clinical Record - Narrative Summary. Clinical Record - Autopsy Protocol. Medical Record - Abbreviated Medical Record. Clinical Record - History - Parts II. Clinical Record - History - Parts II and III. Clinical Record - Physical Examination. Clinical Record - Newborn. Medical Record - Doctor's Progress Notes. Medical Record - Emergency Care Treatment. Nursing Care Plan (See AR 40-407). Medical Record - Nursing Assessment and Care Plan Continuation (See AR 40-407). Nursing Notes. Medical Record - Vital Signs Record (See AR 40-407). Clinical Record - Plotting Chart.

Table 1-1. Filing sequence for documents in ITR folder (continued).

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RIGHT SIDE OF FOLDER Form Number SF 513/ DD Form 2161 SF545 SF 515 SF 516 SF 517 SF 518 SF 519B SF 520 SF 522 Form Title and Notes Medical Record - Consultation Sheet/Referral for Civilian Medical Care. Laboratory Report Display. Medical Record - Tissue Examination. Medical Record - Operation Report. Clinical Record - Anesthesia. Medical Record - Blood or Blood Component Transfusion. Radiologic Consultation Request/Report. Clinical Record - Electrocardiographic Record. Medical Record - Request for Administration of Anesthesia and for Performance of Operations and Other Procedures (See AR 40-3). Clinical Record – Authorization for Autopsy. Medical Record - Disposition of Body. Medical Record - Authorization for Tissue Donation. Medical Record - Radiation Therapy. Medical Record - Radiation Therapy Summary. Medical Record - Interstitial Intercavitary Therapy Medical Record - Group Muscle Strength, Joint R.O.M. Girth and Length Measurements. Medical Record - Muscle Function by Nerve Distribution: Face, Neck, and Upper Extremity. Medical Record - Muscle Function by Nerve Distribution: Trunk and Lower Extremity. Clinical Record - Neurological Examination. Medical Record - Anatomical Figure. Medical Record - Prenatal and Pregnance (and relate prenatal documents). Medical Record - Labor. Clinical Record - Pediatric Nursing Notes. Medical Record - Pediatric Graphic Chart. Clinical Record – Pediatric. Medical Record - Gynecological Cytology. Medical Record - Electroencephalogram Request and History.

SF 523 SF 523A SF 523B SF 524 SF 525 SF 526 SF 527 SF 528 SF 529 SF 530 SF 531 SF 533 SF 534 SF 536 SF 537 SF 538 SF 541 SF 560

Table 1-1. Filing sequence for documents in ITR folder (continued).

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RIGHT SIDE OF FOLDER Form Number DA Form 3824 DA Form 4221 DA Form 4221 DA Form 4256 DA Form 4677 DA Form 4678 DA Form 4700 DA Form 5128 DD Form 602 DD Form 741 DD Form 749 DD Form 1380 DA Form 4359-R DA Form 2985 DA Form 4410-R DD Form 2005 Form Title and Notes Urologic Examination. Diabetic Record. Diabetic Record. Doctor's Orders. Therapeutic Documentation Care Plan (Non-Medication (See AR 40-407). Therapeutic Documentation Care Plan (Medication) (See AR 40-407). Medical Record - Supplemental Medical Data. Clinical Record - Visual Field Examination. Patient Evacuation Tag (See AR 40-40). Eye Consultation. Clinical Record - Head Injury (for file purpose only). U.S. Field Medical Card. Authorization for Psychiatric Service. Treatment (See AR 40-3). Medical Reports on a stillborn infant. (Filed in the mother's ITR.) Admission and Coding Information. Disclosure Accounting Record. To be included when preprinted DA Form 3444 series folders are not used. Privacy Act Statement - Health Care Records. To be included when preprinted DA Form 3444 series folders are not used

Table 1-1. Filing sequence for documents in ITR folder (concluded).

1-20. DISPOSITION OF RECORDS a. Termination of Treatment. When the patient is discharged from the hospital at the end of treatment, the ITR must be completed before filing. (1) Attending physician. The attending physician completes the worksheet copy of the ITRCS. The attending physician dictates the Narrative Summary and makes final progress notes on SF 509 or SF 539. When this is accomplished, the physician forwards the ITR to the Patient Administration Division.

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(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 1-34

Medical Center and Womack Army Medical Center. MEDCENs are usually teaching hospitals. (1) Teaching hospitals. A teaching hospital provides advanced training such as the training of interns and residents. In a MEDCEN or teaching hospital, Inpatient Treatment Records are maintained five years after the year of disposition (the treatment year). ITRs are: (a) Held for five years after the year of disposition. (b) Retired after the five-year holding period. Example: Treatment Year Holding Years Date of Retirement = 1993 = 1994, 1995, 1996,1997, 1998 = January 1999

(2) Nonteaching hospitals. Medical treatment facilities having no official training program are classified as nonteaching hospitals. In a nonteaching hospital, ITRs are: (a) Held for one full year after the year of disposition (the treatment year). (b) Retired after the one-year holding period (unless the patient has been readmitted). Example: Treatment Year Holding Year Date of Retirement e. Retrieval of Records from Storage. (1) When medical records (to include ITRs) are retired, they are sent to a repository (storage area) in St. Louis, Missouri. (2) To retrieve retired records from the repository, a physician must advise PAD of the need for the record. PAD, in turn, must send a written request to St. Louis. After the record is no longer needed, it is returned to the repository in St. Louis. If required indefinitely, the record may be retained; however, written notification must be sent to the repository. = 1993 = 1994 = 1995

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f. Access and Audit Trail. Access must be given to ITRs on file or to cases having register numbers. In addition, a record audit trail must be kept. Two indexes will be kept for this purpose, the nominal index and the register number index. (1) Nominal index. The nominal index will include a card for each patient assigned a register number. Each card will list the patient's name, SSN with FMP, and register number. The cards will be filed alphabetically by last name. If the patient is transferred, the date of transfer and the name of the receiving MTF will be noted on the card. A manual nominal index is not required for those MTFs using AQCESS (Automated Quality of Care Evaluation Support System), CHCS (Composite Health Care System), or other automated patient data systems. (2) Register number index. A MEDCEN does not need to maintain this index, because the ITRs are maintained for 5 years. A MEDDAC (Medical Department Activity) will maintain a register number index for 5 years. The register number index will include a copy of DA Form 3647 for each patient assigned a register number. A copy of SF 502 (when prepared) may be attached to the DA Form 3647. This index will be kept in register number sequence. For transfer cases, a copy of the transmittal form will be attached to DA Form 3647.

Continue with Exercises

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EXERCISES, LESSON 1 INSTRUCTIONS: Answer the following exercises by marking the lettered response that best answers the exercise, by completing the statement, or by writing the answer in the space provided at the end of the exercise. After you have completed all the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers with the solutions. For exercise 1 through 7, place one of the codes listed below in the blank after each statement to indicate the type of inpatient treatment record that should be initiated: a = Routine ITR b = Abbreviated ITR c = CRO ITR d = No ITR

1. An infant is born dead. ___

2. The patient is hospitalized four days with a bleeding ulcer. ___

3. The patient enters the hospital for heart surgery. ___

4. A patient breaks his arm and remains in the hospital overnight. ___

5. The patient is hospitalized overnight for a tonsillectomy (minor surgery). ___

6. The patient is DOA at the hospital from a drug overdose. ___

7. A rape victim is examined and treated. ___

8. The forms and reports filed in an ITR depend on ________________________

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9. Why is the use of a rubber block stamp under the signature on ITRs recommended? ________________________________________. 10. List the three requirements of the physical examination for the inpatient. a. ______________________________. b. ______________________________. c. ______________________________. 11. List the minimum requirements of patient identification on an ITR. ________________________________________________________________

12. The Narrative Summary is prepared upon disposition of the patient. What must be included in the Narrative Summary? ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ 13. List the functions of medical records. ______________________________ ______________________________ ______________________________ ______________________________

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14. When a patient is discharged upon termination of treatment, the attending physician is required to complete the ITR before forwarding it to the PAD. List the three things the physician must do to complete the ITR. a. ______________________________ b. ______________________________ c. ______________________________ 15. What action should be taken when PAD personnel review the ITR and find information or a signature is missing? ________________________________________________________________

16. Define a teaching hospital. ________________________________________________________________

Check Your Answers on Next Page

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SOLUTIONS TO EXERCISES, LESSON 1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. d. a. a. b. b. c. c. (para 1-4b) (para 1-6a) (para 1-6c) (para 1-7a) (para 1-7a) (para 1-8a) (para 1-8c)

The nature of the case and treatment given. (para 1-9a) To identify the person making the entry. (para 1-10c) a. b. c. The physical examination must be current (must have been completed within the 24 hours period preceding the examination). The physical examination must be related to the illness for which the patient is hospitalized. Findings must be recorded in specific terms. (para 1-12b)

11.

Patient's name, rank, grade or status, family member prefix, sponsor's SSN, and register number (para 1-11a) Reason for hospitalization. All significant findings. All procedures performed and treatment given. Condition of patient at time of transfer or discharge. Discharge instructions. All relevant diagnosis. (para 1-17a) To provide a written record of the treatment and care of each patient when he is hospitalized. To demonstrate compliance with Army regulations and JCAHO standards. To provide a measure of the quality of patient care. To provide legal documentation of patient care. (para 1-18) a. b. c. Complete the ITRCS worksheet. Dictate the Narrative Summary. Make final progress notes. (para 1-20a(1))

12.

13.

14.

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15.

The ITR must be returned to the physician or nurse for completion. (para 1-20a(2) One in which official training is provided. (para 1-20d(1))

16.

END OF LESSON 1

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LESSON ASSIGNMENT

LESSON 2 LESSON ASSIGNMENT LESSON OBJECTIVES

Diagnostic and Operative Coding. Paragraphs 2-1 through 2-19. After completing this lesson, you should be able to: 2-1. Properly code the diagnoses, operations, and procedures provided in the lesson exercise, through the use of the ICD-9-CM. 2-2. Identify the general characteristics of the ICD-9-CM Tabular List, Alphabetical Index, and the Procedures Classification Manual Book.

SUGGESTION

After completing the assignment, complete the exercises of this lesson. These exercises will help you to achieve the lesson objectives.

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LESSON 2 DIAGNOSTIC AND OPERATIVE CODING

Section I. GENERAL

2-1. INTRODUCTION Statistical information is used for research, training, manpower requirements, budget requirements, and future planning for the medical community. One of the elements of statistical information is the numerical classification of diseases, injuries, and operative procedures. Medical terminology does not blend into the computerized statistical reports required by the Army, so a numerical classification is used. You may recall from the lesson you had in admission and disposition procedures the use of the ICD-9-CM code number on the imprinting plate which was initiated at the time of admission. In this lesson, you will learn the process of coding diseases, injuries, and operative procedures and put that knowledge to practical use in your work in the Patient Administration Division (PAD). 2-2. CLASSIFICATION OF DISEASES AND PROCEDURES a. The resource used in the classification of diseases and medical procedures is the International Classification of Diseases-9th Revision Clinical Modification (ICD-9-CM). The ICD-9-CM consists of three volumes which are based on the International Classification of Diseases, 9th Revision (ICD-9) published by the World Health Organization. These references provide for classification of morbidity and mortality information for statistical purposes and for indexing of hospital records by disease and by medical operation to facilitate data storage and retrieval. b. History and Development of the ICD-9-CM. In February 1977, a steering committee was convened by the National Center for Health Statistics to provide advice and counsel to the development of a clinical modification of the International Classification of Diseases, 9th Revision. As a result of this steering committee's efforts, the ICD-9-CM was published in 1979. The second edition that you are using is probably dated September 1980. The term "clinical" is used to emphasize the modification's intent; to serve as a useful tool in the area of classification of morbidity data for indexing of medical records, medical care review, ambulatory and other medical care programs, as well as for basic health statistics. To describe the clinical picture of the patient, the codes must be more precise than those needed only for statistical grouping and trend analysis. c. The ICD-9-CM is totally compatible with its parent system, the ICD-9, thus meeting the need for comparability of morbidity and mortality statistics at the international level.

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2-3. GENERAL CHARACTERISTICS OF THE ICD-9-CM, TABULAR LIST (VOL I) a. Volume I, The Tabular List. This volume of the ICD-9-CM is arranged in seventeen major sections, each covering a category of diseases (see figure 2-1). The first category covers diseases caused by well-defined infective agents. The subsequent categories cover: neoplasms; endocrine; nutritional, and metabolic diseases. Most of the remaining diseases are arranged according to their principal anatomical site. There are special sections for mental diseases, complications of pregnancy and childbirth, certain diseases peculiar to the perinatal period, and ill-defined conditions including symptoms. b. A decimal system of numbering has been adopted in which the detailed categories of the classification are designated by three-digit numbers. In many instances, the first two digits of the three-digit number designate important or summary groups of significance. The third digit divides each group into categories which represent specific disease entities or a classification of the disease or condition according to some significant axis, such as anatomical site. (1) The fourth-digit subcategories provide further specificity or additional information about the etiology or manifestations of the disease. Also, when appropriate and possible to include residual subcategories for "other" and "unspecified," these have been numbered consecutively 8 and 9, respectively. (2) Optional fifth digits are provided in certain places; for example, for the mode of diagnosis in tuberculosis and for anatomical site in musculoskeletal disorders. 2-4. GENERAL CHARACTERISTICS OF THE ICD-9-CM, DISEASES (ALPHABETICAL) INDEX (VOL 2) a. Volume 2 of the ICD-9-CM is referred to as an Alphabetical Index. This index is used in conjunction with the Tabular List of Volume 1. In coding, you should always refer to the Tabular List and its notes to ensure that the code given by the index fits the circumstances of a particular case. b. The ICD-9-CM Alphabetical Index is an essential adjunct to the Tabular List; it contains a great number of diagnostic terms which do not appear in Volume 1. The terms included in a category of the Tabular List do not make up an exhaustive list of terms. Rather, the terms provide examples of the content of the category. The Alphabetical Index, on the other hand, is intended to include all diagnostic terms currently in use. c. Because of its exhaustive nature, the Alphabetical Index inevitably includes many imprecise and undesirable terms. Since these terms are still occasionally encountered on medical records, coders need an indication of their assignment in the classification, even if this is to a rubric (title) for residual or ill-defined conditions.

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TABLE OF CONTENTS FOREWARD PREFACE ACKNOWLEDGMENTS INTRODUCTION CONVENTIONS USED IN THE TABULAR LIST GUIDANCE IN THE USE OF ICD-9-CM CLASSIFICATION OF DISEASES AND INJURIES 1. Infectious and Parasitic Diseases 2. Neoplasms 3. Endocrine, Nutritional and Metabolic Diseases, and Immunity Disorders 4. Diseases of the Nervous System and Sense Organs 5. Mental Disorders 6. Diseases of the Nervous System and Sense Organs 7. Diseases of the Circulatory System 8. Diseases of the Respiratory System 9. Diseases of the Digestive System 10. Diseases of the Genitourinary System 11. Complications of Pregnancy, Childbirth, and the Puerperium 12. Diseases of the Skin and Subcutaneous Tissues 13. Diseases of the Musculoskeletal System and Connective Tissue 14. Congenital Anomalies 15. Certain Conditions Originating in the Perinatal Period 16. Symptoms, Signs, and Ill-Defined Conditions 17. Injury and Poisoning SUPPLEMENTARY CLASSIFICATION Classification of Factors Influencing Health Status and Contact with Health Service Classification of External Causes of Injury and Poisoning APPENDICES A. Morphology of Neoplasms B. Glossary of Mental Disorders Figure 2-1. Volume 1, Table of Contents. (Continued) 880 930 1 81 154 188 204 251 358 404 432 481 527 569 593 639 683 707 735 iii v vii xv xxiii xxv

1055 1077

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C. Classification of Drugs by American Hospital Formulary Service List Number and Their ICD-9-CM Equivalents D. Classification of Industrial Accidents According to Agency E. List of Three Digit Categories

1127

1137 1143

Figure 2-1. Volume 1, Table of Contents. (Concluded) The presence of a term in this volume, therefore, should not be taken as sanction for its usage in good medical terminology. 2-5. GENERAL CHARACTERISTICS OF THE ICD-9-CM, PROCEDURES MANUAL (VOLUME 3)

a. The structure of the Procedures Manual is similar to that of the Volumes 1 and 2. Volume 3 contains a tabular list and an alphabetical index. b. The complete series of categories for the 16 chapters of the Volume 3 are numbered from 010 to 9999. The classification is significant at the three-digit level; the fourth-digit provides for greater detail and precision. 2-6. CODING PRINCIPLES

a. Certain diagnoses are coded according to specific rules. Appendix A of this lesson contains excerpts, (modified for instructional purposes) taken from the Individual Patient Data System (IPDS) User's Manual of the U.S. Army Medical Command, U.S. Army Patient Administration Systems and Biostatistics Activity. The excerpts provide coding principles to be used in diagnostic and operation coding. b. The IPDS User's Manual includes more principles than are included in this lesson. Principles discussed in this lesson have the same number as the principles in the User's Manual. This will enable you to identify the principles omitted from this lesson. c. Since the actual ICD-9-CM, Volumes 1, 2, and 3 cannot be provided, the following data is provided to indicate where the pages cited in this lesson may be found in the directive: (1) See Appendix B for "Excerpts from Volume 1, ICD-9-CM." (2) See Appendix C for "Excerpts from Volume 2, ICD-9-CM." (3) See Appendix D for "Excerpts from Volume 3, ICD-9-CM."

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Section II. CONVENTIONS AND TERMINOLOGY 2-7. GENERAL

The following paragraphs explain (and provide examples of) the signs, symbols, abbreviations, and instructions you will encounter in using the ICD-9-CM. Most of this information can also be found in the IPDS User's Manual. 2-8. INSTRUCTIONAL TERMS

a. Inclusion Terms. These are secondary terms which indicate that the code and title embrace these terms. Inclusion terms are not to be taken as all-inclusive, but rather as an example of the terms included. 030 Leprosy Includes: Hansen's disease infection by Mycobacterium leprae b. Exclusion Terms. These are secondary terms indicating that the conditions/procedures are not included but may be found elsewhere. Exclusion terms are always written in italics and the word excludes is written in italics and in a box. EXAMPLE: 117.6 Allescheriosis [Petriellidosis] Infections by Allescheria [Petriellidium] boydii [Monosporium apiospermum]

Excludes: mycotic mycetoma (117.4) c. NOTE. Found throughout the ICD-9-CM manuals (all volumes), and directs the coder toward specific classification assignments. EXAMPLE: Choledocholithiasis 574.5

Note--Use the following fifth-digit subclassification with category 574: 0 without mention of obstruction 1 with obstruction with cholecystitis (chronic) 574.4 acute 574.3

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d. See. Refers the coder to another diagnosis. The code will not be given at the first point. This makes it absolutely necessary that the coder refer to an additional term. EXAMPLE: Hardening artery — see Arteriosclerosis brain 348.8 liver 571.8 e. See category. Refers the coder to Volume 1. This pertains to three-digit classifications. For most accurate coding, this step is essential. EXAMPLE: Fever — continued cerebral 323.9 late effect — see category 326 f. See also. Refers coder to another diagnosis (usually placed in parentheses), and a code number will be provided in both places. Occasionally, the code will differ. EXAMPLE: Apophysitis (bone) see also Osteochondrosis) 732.9 calcaneus 732.5 juvenile 732.6 g. Omit code. Used primarily in Volume 3 when the procedure is the method of approach for an operation. EXAMPLE: Laparotomy NEC 54.19 as operative approach -- omit code exploratory (pelvic) 54.11 reopening of recent operative site (for control of hemorrhage) (for exploration) (for incision of hematoma) 54.12 NOTE: If a laparotomy incision was made for abdominal surgery, the code for laparotomy would not be used.

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h. Code also. Used when more than one code is necessary to fully identify a given condition or procedure. Code also is used in Volume 1 and Volume 3 to code the cause of the condition (etiology) or each component of the procedure. EXAMPLE: Volume 1 774.5 Perinatal jaundice from other causes Code also underlying cause, as: congenital obstruction of bile duct (751.61) galactosemia (271.1) mucoviscidosis (277.00-277.01) EXAMPLE: Volume 3 42.42 Total esophagectomy Code also any synchronous: gastrostomy (43.1-43.2) interposition or anastomosis other than end-to-end (42.51-42.69) Excludes: esophagogastrectomy (43.99) i. Use additional code. Appears only in Volume 1. More than one code is used to more accurately describe the diagnosis. When coding in a military MTF disregard "if desired" and assign the additional code. EXAMPLE: 491 Chronic bronchitis Use additional code, if desired, to identify acute exacerbation (466.0-466.1)

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2-9. PUNCTUATION MARKS a. Parentheses ( ( ) ). Used to enclose supplementary words that may or may not be stated as part of the physician's diagnosis/ procedure, and that do not change the appropriate code. EXAMPLE: Hypophosphatemia (acquired) (congenital) (familial) 275.3 renal 275.3

b. Square brackets ( [ ] ). Used to enclose synonyms, alternate wording, or explanatory phrases or reference assignable 5th digit specificity. Square brackets are also used to give you an additional code that is needed code. EXAMPLE: 50.1 Diagnostic procedures on liver 50.11 Percutaneous [needle] biopsy of liver Diagnostic aspiration of liver

c. Colons (:). Indicates an incomplete term or phrase that must have one of the modifiers (which follow) in order to make it assignable to the specific category. EXAMPLE: 491.1 Mucopurulent chronic bronchitis Bronchitis (chronic) (recurrent): fetid mucopurulent

d. Braces ( } ). Used to connect a series of words to a common term. EXAMPLE: 250.1 Diabetes with ketoacidosis; Diabetic: adidosis ketosis } without mention of coma

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2-10. ABBREVIATIONS a. Not elsewhere classifiable (NEC). Added after terms classified in unspecified categories and to terms in themselves ill-defined. The category number for the term including NEC is to be used only when the coder lacks the information necessary to code the term to a more specific category. If the medical record includes more precise information, the coding should be modified accordingly. NEC is used in the Alphabetical Indexes Volume 2 and Volume 3. EXAMPLES: Aborter, habitual or recurrent NEC without current pregnancy 629.9 current abortion (See also Abortion, spontaneous) 634.9 affecting fetus or newborn 761.8 observation in current pregnance 646.3 Lavage antral 22.00 bronchus NEC 96.56 endotracheal 96.56 gastric 96.33 b. Not otherwise specified (NOS). Is equivalent to "unspecified." NOS is used in the Tabular Lists (Volume 1 and Volume 3). EXAMPLES: 250.0 Diabetes mellitus without mention of complication Diabetes mellitus without mention of complication or manifestation classifiable to 250.1-250.9 Diabetes (mellitus) NOS 16.49 Other enucleation of eyeball Removal of eyeball NOS 2-11. SYMBOLS a. Lozenge ( ¨ ). Found only in Diseases Tabular List (Volume 1). The lozenge is printed in the left margin preceding the disease code. It denotes a four-digit rubric (title) unique to ICD-9-CM. The lozenge has no effect on coding, it is used for comparison studies with ICD-9. EXAMPLE: 250.2 Diabetes with hyperosmolar coma Hyperosmolar (nonketotic) coma

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b.

Section mark ( § ). Denotes a footnote at the bottom of the page and is applicable to all subdivisions within that code. The section mark may refer to requirement of a fifth digit.

EXAMPLE: §38.4 Resection of vessel with replacement

[0-9] Angiectomy Excision of: Aneurysm (arteriovenous) Blood vessel (lesion)

with replacement

Requires fourth digit; valid digits are in [brackets] under each code. See page 99 for definitions.

2-12. RELATED TERMS a. See condition. Refers the coder to the term identifying the specific disease or injury of the patient. This instruction is most frequently seen when the coder looks for the body part as the main term instead of the specific disease or injury (i.e., deformity of the hand). If the coder looks under the main term hand, it will read "see condition." Deformity is the condition. EXAMPLE: Hand — see condition b. And. Indicates involvement of either or both terms/sites. EXAMPLE: 31 Other operations on larynx and trachea 31.0 Injection of larynx Injection of inert material into larynx or vocal cords c. With. Indicates that both terms must be present and part of the diagnoses or procedure stated by the physician. EXAMPLE: § 38.1 Endarterectomy [0-6.8] Endarterectomy with: embolectomy patch graft temporary bypass during procedure thrombectomy

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Section III. USE OF ICD-9-CM 2-13. GENERAL a. In the ICD-9-CM, the tabular list is in Volume 1 and the alphabetical index is in Volume 2. Having the alphabetical index in a separate volume eliminates turning pages back and forth and makes it easier to verify codes in Volume 1. Volume 3, the procedures manual, contains both the tabular list and alphabetical index. The alphabetical index is located at the back of Volume 3. b. As explained in lesson 1, each ITR must have two copies of an ITRCS: a handwritten physician's work copy and a typewritten copy. The physician writes the diagnoses and any procedures the patient undergoes on the work copy of the ITRCS. When the work copy is received in the Patient Administration Division, you locate the diagnostic or procedural codes in the ICD-9-CM. These codes are entered on the typewritten copy (see figure 2-2). c. Since medical nomenclatures (names) may be obtained from laboratory reports, radiological reports, consultations, and other sources where information is recorded by approved and authorized clinicians, medical officers, and dental officers, the patient administration specialist must check the clinical record thoroughly for any nomenclature or qualifying terms that may have been overlooked. Although the ICD-9-CM set of volumes is not provided to physicians for their use as guides in expressing diagnoses, physicians are not precluded from using them to assist medical records personnel in the proper coding of diseases and surgical procedures. d. The nomenclature of a diagnosis or procedure must be as explicit and complete as possible. In addition to the name of the disease or pathological condition, body parts or anatomical sites must be given, when relevant, and terms such as "right," "left," "bilateral," "posterior," and "anterior" must be included, when applicable. e. In coding diseases and injuries, you should locate the diagnoses in the Alphabetical Index, Volume 2, then verify the diagnoses in the Tabular List, Volume 1. Close attention to any notes or directions found in Volume 1 is necessary for accurate coding. Since you must begin the coding process with the Alphabetical Index of Volume 2, it will be covered first. 2-14. ARRANGEMENT OF THE ALPHABETICAL INDEX a. The Alphabetical Index is divided into three sections. (1) Section I, "Alphabetical Index to Diseases and Injuries." This section contains an alphabetical index of diseases, injuries, and other conditions, except poisoning or other adverse effects of drugs and other chemical substances.

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Figure 2-2. ITRCS (handwritten and typed copies) (continued).

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Figure 2-2. ITRCS (handwritten and typed copies) (concluded).

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(2) Section II, "Table of Drugs and Chemicals ." This section is not used by the Army. Instead, Appendix C of the Individual Patient Data System (IPDS) User's Manual is used. This User's Manual is a publication of the U.S. Army Medical Department Center and School, Directorate of Patient Administration Systems and Biostatistics. (3) Section III, "Alphabetical Index to External Causes of Injuries and Poisonings." These terms are not medical diagnoses, but describe the circumstances under which an accident or act of violence occurred (i.e., the underlying cause or means of injury). Use of this section by the Army is limited. It will be discussed later in this lesson. b. As mentioned earlier, Volume 2 is arranged alphabetically (see figure 2-3). In first order are the main terms (names or nomenclatures of diagnoses). Next, are the modifiers of the main terms. Main terms are printed in bold face type. Modifiers are indented under the main terms. As you see in the example below, each level of indentation modifies or relates to the level above it. The arrangement is similar to that of an outline. (1) Modifiers indented 2 spaces modify or relate to the main term. (2) Modifiers indented 4 spaces modify or relate to the nearest 2 space indentation. (3) Modifiers indented 6 spaces modify or relate to the nearest 4 space indentation. (4) The same principle applies regardless of the number of levels of indentation under a main term. EXAMPLE: Aphthae, aphthous — see also condition Bednar's 528.2 cachectic 529.0 epizootic 078.4 fever 078.4 oral 528.2 stomatis 528.2 thrush 112.0 ulcer (oral) (recurrent) 528.2 genital organ(s) NEC female 629.8 male 608.89

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Figure 2-3. Example of alphabetic arrangement of Volume 2, ICD-9-CM (showing indentation of main terms and modifiers).

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2-15. STEPS IN USING VOLUME 2 Here are the steps for using Volume 2, ICD-9-CM recommended by the IPDS User's Manual: a. Locate the condition (main term) in the Alphabetical Index. The main term is printed in bold face type for ease of reference. Main terms will identify disease conditions (Aphthae, aphthous) or state the actual problem (Infarction). A main term may be followed by a series of terms in parentheses and may also be followed by a list of subterms (modifiers) which are indented two spaces. A main term can never be a body part or organ such as heart, artery, or stomach. Be sure to start at the main term. b. Look for eponyms (diseases or operations named after a person, e.g., Parkinson's disease) under the person's name or under the main terms "Disease" or "Syndrome" or "Tremor." c. Look for conditions expressed as adjectives (e.g., irregular) in the list of main terms. d. Be sure to read and follow any "NOTE" listed under the main term. A note is usually found at the beginning of a main term, but is not repeated on continuing pages. e. Read terms enclosed in the parentheses following the main term and modifiers. f. Be guided by the "see" and "see also" in cross-referencing synonyms and closely related terms. Remember that "see condition" usually indicates that you have located the body part in the index rather than the disease or injury of that part. g. Use E-codes (E930-E949) to identify adverse effects of drugs and chemicals properly administered. The Army uses only E-codes under the heading "Adverse Effect In Correct Usage." These E-codes will require a "Cause of Injury" code from the IPDS User's Manual. This is discussed in greater detail later in this lesson. h. Use V-codes (V01-V82) when a person who is not currently ill is hospitalized for some specific purpose such as birth, observation, or to donate an organ. When some circumstance or problem is present which influences the person's health status but is not in itself the cause of admission, V-codes are used as supplementary codes. i. The Hypertension Table is found under the main term "Hypertension." This table contains a complete listing of all conditions due to or associated with hypertension and classifies them according to malignant (life-threatening), benign (not lifethreatening), and unspecified condition. j. Neoplasms are listed in the Alphabetic Index in two ways: anatomic site and morphology (structure of the organ or part). Morphology codes may be used at the local

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level by the Tumor Registry in military services facilities. The comprehensive list by anatomic sites is found in a Neoplasm Table under the main term "Neoplasm, neoplastic." The table contains six columns: primary, secondary, and in situ if diagnosed as malignant and benign, uncertain behavior, or unspecified. 2-16. ARRANGEMENT OF THE TABULAR LIST a. As explained earlier, the Tabular List, Volume 1, is arranged in 17 main sections (see figure 2-1) which are in numerical order by three-digit numbers. The first two digits indicate important or summary groups (e.g., 01 Tuberculosis, 40 Hypertensive Heart Disease). The third-digit divides each group into categories representing specific disease entities or the classification of the disease or condition, such as anatomical site (e.g., 810 Fracture of Clavicle, 812 Fracture of Humerus). b. There are also fourth-digit numbers which appear after a decimal. (Military services facilities disregard the decimal.) The fourth-digit provides more information about the disease or condition (e.g., 157.1 Body of pancreas, 157.2 Tail of pancreas). EXAMPLE: 157 Malignant neoplasm of pancreas 157.0 Head of pancreas 157.1 Body of pancreas 157.2 Tail of pancreas 157.3 Pancreatic duct c. In some places, "optional" fifth-digit classifications are provided for even more specificity (e.g., 715.01 Osteoarthrosis, generalized of the shoulder region, 714.02 Osteoarthrosis, generalized of the upper arm). Such classifications are usually at the beginning of a chapter or at the beginning of a three-digit category. Although ICD-9-CM states that these are optional, the Army requires that these classifications be used. 2-17. STEPS IN USING VOLUME 1 a. Verify that the code number selected from the Alphabetical Index (Volume 2) is appropriate with the correct diagnostic classification. b. Read all inclusions, exclusions, and notes under the selected code. Remember that these may be at the beginning of a chapter or a three-digit category. c. Disregard decimal points appearing in ICD-9-CM when coding a disease or cause of injury diagnosis.

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d. Use secondary codes if indicated by "Use additional code, if desired. . ." The Army requires the use of secondary codes. e. Use fifth-digit codes in ICD-9-CM, Volume 1 to identify manifestations of diseases. f. Use DOD extender codes as provided in Appendix A of the Triservice Disease and Procedures Coding Guidelines (ICD-9-CM), dated 1 January 1991. (See Coding Principles in Appendix A of this subcourse.) g. Verify the code at the main 3-digit category for any added instructions. 2-18. ARRANGEMENT OF THE PROCEDURES CLASSIFICATION Volume 3 is the Procedures Classification book. Volume 3 contains two major subdivisions : the Tabular List of Procedures and the Alphabetic Index to Procedures. TABLE OF CONTENTS FOREWARD PREFACE ACKNOWLEDGMENTS INTRODUCTION CONVENTIONS USED IN THE TABULAR LIST CONVENTIONS USED IN THE ALPHABETIC INDEX Tabular List 1. Operations on the Nervous System 2. Operations on the Endocrine System 3. Operations on the Eye 4. Operations on the Ear 5. Operations on the Nose, Mouth, and Pharynx 6. Operations on the Respiratory System 7. Operations on the Cardiovascular System 8. Operations on the Hemic and Lymphatic System 9. Operations on the Digestive System 10. Operations on the Urinary System 11. Operations on the Male Genital Organs 12. Operations on the Female Genital Organs 13. Obstetrical Procedures 14. Operations on the Musculoskeletal System 15. Operations on the Integumentary System 16. Miscellaneous Diagnostic and Therapeutic Procedures Alphabetic Index Figure 2-4. Volume 3, Table of Contents. iii v vii xv xxiii xxv

1 15 22 46 53 71 83 110 114 155 172 181 198 205 238 248 301

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a. The Tabular List. The structure of classification is based on anatomy rather than surgical specialty (see figure 2-4). There are 16 chapters in the Tabular List. The first 15 chapters refer to the anatomical systems, whereas chapter 16 refers to miscellaneous diagnostic and therapeutic procedures. (1) The procedure code is based on a two-digit section code with two decimal digits where necessary (the Army disregards the decimal). The two-digit section code provides a heading by site and general description of the procedure. The three-digit category code specifies the procedure. The four-digit subcategory code provides greater specificity in identifying anatomical sites and defining selected procedures, techniques, or the surgical approach. (2) All surgical or procedure codes will contain three or four-digits. Do not zero-fill to the right for three-digit codes. EXAMPLE: 30 Excision of larynx 30.0 Excision or destruction of lesion or tissue of larynx Marsupialization of laryngeal cyst Other excision or destruction of lesion or tissue of larynx Stripping of vocal cords Excludes biopsy of larynx (31.43) laryngeal fistulectomy (31.62) laryngotracheal fistulectomy (31.62)

30.01 30.09

b. The Alphabetic Index to Procedures. This index follows the same basic format as Volume 2.

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2-19. STEPS IN USING VOLUME 3 a. Begin with the Alphabetic Index. Locate the main term which will be in bold type. NOTE: Do not code directly from the Alphabetic Index. b. Refer to the Tabular List to verify that the code number you have selected is in accord with the procedure performed. NOTE: There are many exclusion notes in the Tabular List. Read and be guided by the exclusion terms and exclusion notes under the category and subcategory. c. Follow the instructions and any note to "code also." Use two or more codes to completely code each component of a procedure. NOTE: Remember the surgical approach and closure are part of the operation and do not require codes in addition to the code for the operations, unless they are unusual or required by the statement "code also." d. Verify the code at the main 2-digit category for any added instructions.

Continue with Lesson Exercises

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EXERCISES, LESSON 2 REQUIREMENT. Complete the following exercises by marking the lettered response that best answers the question, or by finishing the incomplete statement, or by writing the answer in the space provided at the end of the question. After you have completed the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers with the solutions.

1.

List the document that is used in classifying diseases and medical procedures: ___________________________________.

2. In coding diseases, the Alphabetical Index of the ICD-9-CM is used in conjunction with: ___________________________________.

3.

What is the first step in coding a diagnosis? ___________________________________.

4.

What is the second step in coding a diagnosis? ___________________________________.

5. Which copies of the Inpatient Treatment Record Cover Sheet (ITRCS) are found in the Inpatient Treatment Record (ITR)? a. ______________________________. b. ______________________________.

6. How are modifiers identified in the Alphabetical Index, Volume 2, of the ICD-9-CM? ___________________________________.

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7. State two ways to locate a diagnosis in the Alphabetical Index, Volume 2 of the ICD-9-CM, when that diagnosis begins with an eponym. a. ______________________________. b. ______________________________.

8. Which codes are used in the Alphabetical Index, Volume 2 to identify adverse effects of drugs and chemicals that were properly administered? ___________________________________.

9. In the Tabular List of Volume 1 of ICD-9-CM, the first two digits of the number indicate: ___________________________________.

10. What is the function of the third digit of a three-digit number in the tabular list of volume 1 of ICD-9-CM? ___________________________________.

11. What is the Army's policy on the use of the fifth digit in making classifications with the Tabular List of ICD-9-CM? ___________________________________.

12. What should you do when using Volume 1 to verify the code you have selected for a disease or cause of injury diagnosis and a fourth digit is not provided by ICD-9-CM or specified in the IPDS User's Manual? ___________________________________.

13. What type of codes are provided in Appendix A of the Triservice Disease and Procedures Coding Guidelines? __________________________________.

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For exercises 14 through 19, match each of the phrases, signs, symbols, and abbrevations in the left-hand column with the description in the right-hand column that best conveys its usage in the ICD-9-CM.

14.

___ Not Elsewhere Classified (NEC).

a. Equivalent to "unspecified" and "unqualified." b. Used to enclose supplementary as part of the physician’s diagnosis/procedures c. Added after terms classified in unspecific categories and to terms in themselves ill-defined d. Indicates an incomplete term or phrase which must have a certain make it assignable to a specific category e. Used to connect a series of words to a common term. f. Used to enclose synonyms, alternate wording, or explanatory phrases

15.

___ Not Otherwise Specified (NOS).

16.

___ Square Brackets [ ].

17.

___ Parentheses ( ).

18.

___ Braces {}.

19.

___ Colons : .

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Use Appendices B, C, and D, excerpts of the International Classification of Diseases, 9 th Revision, Clinical Modification (ICD-9-CM), to code the diagnoses and procedures in exercises 20 through 33. NOTE: Remember that the Army does not use decimals when coding diseases and procedures.

20. 21. 22.

Swimmer's itch. Wax in the ear. Jaundice (yellow) fetus due to infection Anorexia. Swelling of the tongue. Tooth reimplantation. Lack of physiological development. Stripping varicose veins in upper limb. Colostomy perineal loop. Refusion of spine. Primary malignant neoplasm, liver. Corneal transplant, Keratoplasty with autograft, penetrating (full-thickness). Laryngitis acute with influenza. Goldthwaite operation, ankle stabilization.

_______________ _______________ _______________ _______________ _______________ _______________ _______________

23. 24. 25. 26.

27.

_______________ _______________ _______________ _______________

28. 29. 30. 31.

_______________

32.

_______________

33.

_______________

Check Your Answers on Next Page

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SOLUTIONS TO EXERCISES, LESSON 2 1. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). (para 2-2a) 2. The Tabular Index of Volume 1, ICD-9-CM. (para 2-4a)

3. To locate the diagnoses in the Alphabetical Index, Volume 2, ICD-9-CM. (para 2-13e) 4. 5. 6. To verify the diagnoses in the Tabular List, Volume 1, ICD-9-CM. (para 2-13e) Handwritten physician's work copy and a typewritten copy. (para 2-13b) By indentation under the main term. (para 2-14b)

7. a. Look under the name of the person for whom the disease or operation is named. b. Look under the main terms "Disease," "Syndrome," or "Tremor." (para 2-15b) 8. 9. E-codes. (para 2-15g) Important or summary groups. (para 2-16a)

10. Divides each group into categories representing specific disease entities or the classification of the disease or condition. (para 2-16a) 11. The Army requires that 5th-digit classifications be used for more specificity. (para 2-16c) 12. Disregard decimal points appearing in ICD-9-CM and add a fourth-digit of zero. (para 2-17c) 13. 14. 15. 16. 17. 18. 19. DOD extender codes. (para 2-17f) c (para 2-10a) a (para 2-10b) f (para 2-9b) b (para 2-9a) e (para 2-9d) d (para 2-9c)

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APPENDICES 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 1203 (C-7 and B-1) 3804 (C-9 and B-3) 7741 (C-2 and B-5) 7830 (C-1 and B-6) 7842 (C-7 and B-8) 2350 (D-10 and D-2) 7834 (C-3 and B-7) 3853 (D-11 and D-3) 4603 (D-7 and D-5) 8108 (D-10 and D-6) 1550 (C-5 and B-2) 1163 (D-12 and D-1) 4871 (C-4 and B-4) 8111 (D-8 and D-6)

END OF LESSON 2

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LESSON ASSIGNMENT LESSON 3 LESSON ASSIGNMENT LESSON OBJECTIVES Inpatient Treatment Record Cover Sheet. Paragraphs 3-1 through 3-6. After completing this lesson, you should be able to: 3-1. Identify the purpose of the Inpatient Treatment Record Cover Sheet. 3-2. Identify the medical treatment facilities required to use the Inpatient Treatment Record Cover Sheet. 3-3. Identify the procedures followed in distribution of the Inpatient Treatment Record Cover Sheet. 3-4. Identify the person who is responsible for completing different portions of the Inpatient Treatment Record Cover Sheet. 3-5. Identify and define the information which is extended on the Inpatient Treatment Record Cover Sheet. 3-6. Given a blank Inpatient Treatment Record Cover Sheet, accurately complete it using information provided. SUGGESTION After completing the assignment, complete the exercises of this lesson. These exercises will help you to achieve the lesson objectives.

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LESSON 3 INPATIENT TREATMENT RECORD COVER SHEET Section I. GENERAL

3-1.

GENERAL

a. Purpose. AR 40-66, defines the purposes and use of DA Form 3647, Inpatient Treatment Record Cover Sheet (ITRCS) as a medical and administrative summary of each case. An Inpatient Treatment Record (ITR) consists of the ITRCS and other forms prepared and used during a current, uninterrupted period of treatment for a patient who is hospitalized. The ITRCS is an essential document for the Health Record (HREC) and Outpatient Treatment Record (OTR). It also serves as a source document for statistical information of major military and medical interest, and as a legal document in third party liability cases. b. Use of Inpatient Treatment Record Cover Sheet. All hospitals (fixed and nonfixed) and convalescent centers are required to use the ITRCS. In overseas commands, the ITRCS may also be used, at the discretion of the theater or command surgeon, by clearing stations designated and staffed as nonfixed hospitals. c. For Whom Prepared. The ITRCS is prepared for: (1) All bed patients (military or civilian) admitted to a fixed or field hospital, or convalescent center. (2) Liveborn infants. (3) Carded for Record Only (CRO) cases. CRO is a classification used for: (a) Cases when the patient is dead on arrival at the medical treatment facility (MTF). (b) Disability separations/retirement (medical board) cases processed on an outpatient basis. (c) Selected medicolegal cases such as rape or assault. Such cases require a record for the MTF. d. Responsibilities. (1) The MTF commander has the overall responsibility for the preparation, safeguarding, and forwarding of inpatient records.

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(2) The health care provider is responsible for the day-to-day supervision and maintenance of the inpatient record and for its completion, to include preparation of the professional data on the ITRCS. The information provided on the ITRCS must be adequate for medical, legal, and administrative purposes. (3) The Chief, Patient Administration Division (PAD), is jointly responsible with the health care provider for the preparation of the ITRCS and for other administrative aspects of the ITRCS. (a) The Medical Records Administration Branch acts for the Chief, Patient Administration Division, in completing the administrative aspects of the ITRCS. (b) While each medical treatment facility establishes the procedures for processing the ITRCS, the Medical Records Administration Branch must ensure that the ITRCS is accurate, coded, and complete and that the completed ITRCS is distributed in accordance with AR 40-66 and AR 40-400 upon disposition of the patient. 3-2. DISTRIBUTION

a. Preparation. The ITRCS (DA Form 3647) is one of the forms initiated by Admissions and Dispositions (AAD) at the time a patient is admitted to an MTF. It is completed when the patient is transferred, is discharged, is returned to duty, dies, or is a CRO case. The ITRCS comes in single or continuous form as a four-part carbon pack. Usually, the last copy is used as a worksheet by the attending health care provider. At the time of disposition, the information on the worksheet is transcribed onto the remaining three forms. b. Distribution of ITRCS. The ITRCS is distributed for completed or transferred cases. The original and copies are distributed as follows: (1) The original copy is placed in the ITR. (2) The first carbon copy is placed in the patient's Health Record or Outpatient Treatment Record, as appropriate. (3) The second carbon copy is placed in the register number index, in register number sequence. (4) The third (or last) carbon copy (doctor's handwritten worksheet) is placed after the original typewritten copy in the ITR. NOTE: MEDDACs will maintain a register number index for 5 years. MEDCENs do not need to maintain this index because the ITRs are maintained at the MEDCEN for 5 years. In facilities using the Composite Health Care System (CHCS) or Automated Quality of Care Evaluation Support System (AQCESS), an automated version of DA Form 3647 will be printed. The worksheet copy will not be provided.

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3-3.

ABBREVIATIONS

a. Authorized Abbreviations. AR 40-66 and AR 310-50 contain abbreviations authorized for Army-wide use. b. Other Authorized Abbreviations. Certain other abbreviations are authorized for use in preparing the ITRCS with the exception that all final diagnoses are recorded in full without the use of either symbols or abbreviations. Abbreviations in medical dictionaries as well as common abbreviations found in standard dictionaries are acceptable. Additional abbreviations used on the ITRCS are shown in table 3-1. Absent Sick Accidentally Incurred Against Medical Advice Armed Services Medical Regulating Office Army Community Hospital (e.g., Kirk ACH) Battle Casualty Carded for Record Only Diagnosis Direct Disease Existed Prior to Service Injury Medical Evaluation Board Medical Treatment Facility Multiple Newborn Nonbattle Injury Permanent change of station Permanent Disability Retirement List Physical Evaluation Board Previously Recorded Seriously Ill Subsisting Out Temporary Disability Retirement List Transfer to Army MTF Transfer to Air Force MTF Transfer to Navy MTF Very Seriously Ill Abs Sk AI AMA ASMRO ACH BC CRO Dg Dir Dis EPTS Inj MEB MTF Mul NB NBI PCS PDRL PEB PR SI Sub Out TDRL TAR TAF TNF VSI

Table 3-1. Abbreviations used on the ITRCS

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Section II. COMPLETION OF THE INPATIENT TREATMENT RECORD COVER SHEET 3-4. GENERAL

a. Format. The format is the same for two variations of the Inpatient Treatment Record Cover Sheet (ITRCS). (1) DA Form 3647 (original and three carbon set) used for typed entries of patient data (see figure 3-1). (2) DA Form 3647 (original and three carbon set) used for computer generated, continuous form printing (see figure 3-2). b. Initial Information. The source of data for Items 1 through 30, (except Items 25, 26, and 33) is DA Form 2985 (Admission and Coding Information). DA Form 2985 is a dual purpose form serving as a patient admission information document and coding transcript. It is used in Army medical treatment facilities (MTFs) not having automated admission and disposition/clinical records processing. The initial information is obtained by the admissions clerk. Nonautomated hospitals should complete applicable fields of DA Form 2985 in an original and two legible copies at the time of admission. The information is transferred from DA Form 2985 by typing the items onto DA Form 3647 (see figure 3-3). The remainder of the information is obtained from the ITRCS after the patient is dispositioned and the ITRCS is completed. c. Attending Physician. The health care provider in charge of the case is responsible for the diagnostic/operative information recorded in Item 34, this information is verified by completion of the "Signature of Attending Medical Officer" block on the ITRCS physician's worksheet. d. Disposition Information. This information is completed by the Patient Administration Division at the time of disposition of the patient. The ITRCS is completed when the patient is discharged, returned to duty, transferred, dies, or is a CRO case. This information is covered in detail in the next few paragraphs. e. Recording of Dates. The dates are entered in sequence of day, month, and year. Numerical symbols for months are not authorized. f. CRO Cases. When preparing an ITRCS for CRO cases, Items 7, 14, 24, 27, and 30 and name of admitting officer are not required. g. Correction of ITRCSs. A corrected ITRCS must be completed and forwarded as necessary to correct any item (except for MTF code and register number which cannot be changed in the IPDS data base by the MTF). A corrected ITRCS must include the register number, name of patient, FMP-SSN, date of disposition, and MTF name as well as the information corrected. Both the erroneous entry and corrected

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entry must be shown using the "line out and underline" method. The ITRCS then must be clearly marked as "corrected record" in the top margin and forwarded IAW instructions in lesson 4. 3-5. COMPLETION OF THE ITRCS

a. Items 1 through 30. Nonautomated sites obtain this information from the Admission and Coding Information Form (DA Form 2985) except for Items 25 and 26, and transfer it to the ITRCS (see figure 3-3). The ITRCS is computer-generated by the Automated Quality of Care Evaluation Support System (AQCESS) or the Composite Health Care System (CHCS) in automated sites. b. Item 25, Type Disposition. (1) When a patient is transferred to another U.S. Armed Forces MTF, record the name of the receiving MTF, e.g., TAR Brooke AMC. Continue in Item 31, if necessary. (2) When a military member is placed on change-of- status-out to PCS Home to await the processing of a separation or retirement, the ITR will not be closed out until the effective date of the separation/retirement from service. For these cases, indicate the type and date of the action. (3) Whenever a military member is retired or separated, cite the appropriate Army regulation. For separations under AR 635-200, i ndicate the reason, e.g., failure to meet medical procurement standards, expiration of term of service, etc. When a patient is retired or separated for physical disability, state whether permanent or temporary, or whether separation is with or without severance pay. When a patient is moved to a VA hospital, so state. (4) If a nonmilitary patient leaves the hospital against medical advice, record as "left against medical advice (AMA)." If a military patient leaves the hospital against medical advice, he would be considered absent without leave (AWOL). (5) For a case terminating in death, enter "died" and indicate whether or not an autopsy was performed, e.g., "Autopsy: Yes" or "Autopsy: No."

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Figure 3-1. DA Form 3647 (Inpatient Treatment Record Cover Sheet for typed entries).

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Figure 3-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet for computer generated entries).

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Figure 3-3. Relationship of DA Form 2985 and DA Form 3647.

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c. Item 31, Selected Administrative Data. (1) Board proceedings. Enter the date and findings of Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) proceedings. Include applicable regulation (AR 635-40 or AR 635-200) and paragraph numbers directing separation/retirement. In these cases, also enter the profile(s) necessitating medical separation/retirement. (2) For patients transferred. Enter the Armed Services Medical Regulating Office (ASMRO) cite number, patient movement category, and in the case of urgent or priority cases, the name of the accepting physician. (3) Patient absence. Note if patient is on convalescent or ordinary leave, pass, AWOL (10 days or less), TDY, subsisting out, PCS home, absent sick, or in supplemental care or cooperative care status. Include the appropriate status, name, and location of the facility, and the initial and final dates of treatment for absent sick, cooperative care, or supplemental care. For example, "Supplemental Care to Medical Center Hospital, San Antonio, TX, from 16 MAR 9X to 25 MA R 9X." An ITRCS reflecting a figure in Items 35a through 35d, or 36a through 36d should have that figure broken out in the "Selected Administrative Data" block (Item 31) of the ITRCS. (a) Absent without leave (AWOL). A military patient leaving the MTF without permission will be carried on the rolls as AWOL for 10 consecutive days only. On the 11th day, the Inpatient Treatment Record will be closed out as an AWOL. Should the patient return to the MTF prior to the expiration of 10 days, the date of return will be noted. If the patient returns after 10 days and still requires medical care, the patient will be admitted as a direct admission, assigned a new register number, and a new Inpatient Treatment Record will be initiated. (b) Period of TDY. Patients may, under specific circumstances, be placed on TDY at another hospital or to appear before a Physical Evaluation Board (PEB) or at a military installation. In such cases, an entry will be made of the fact and inclusive dates of the TDY status, e.g., "TDY Ft Sam Houston for PEB appearance 6-11 Sep 9X." (4) Very Seriously Ill (VSI) and Seriously Ill (SI) Patients. AR 40-2 defines these categories of patients and prescribes the preparation of reports and notifications related to them. Remarks will be entered reflecting a clear and chronological outline of the patient's VSI and SI status, e.g., "SI 24 Jun 9X to 25 Jun 9X, removed from VSI/SI Roster 26 Jun 9X or SI 24 Jun 9X and remains SI at time of transfer." (5) Neonatal death. Enter the te rm "Neonatal Death" along with a statement of the infant's age at death. State age in completed hours for death in the first 24 hours of life, in completed days for deaths after the first day of life, e.g., "Neonatal death less than one hour after delivery" or "Neonatal death, age 26 days."

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(6) Newborn to Pay Status . If the mother is discharged and the infant remains, a change of status from newborn to pay status is required. Enter the date of change of status. d. Item 32, Units of Whole Blood/Component Transfused. Record the number of units of whole blood or blood components transfused. (A unit is the basis of issue of blood or blood component.) If no transfusion was given, leave this space blank. e. Item 33, Cause of Injury. (1) If the patient was treated for an injury (including any adverse reaction to chemical or other external cause) or for any residual effects resulting from an injury not previously recorded, state the circumstances under which the injury was incurred. When recording an injury, specify the following: (a) The external causative agent, including, in the case of acute poisoning, the name of the poison. (b) The circumstances under which the injury occurred, including the activity in which the person was engaged at the time of injury, e.g., whether the person was in action against the enemy, on work detail, marching or drilling, on an obstacle course run, handling firearms on the range, cleaning a rifle, or participating in athletics. For motor vehicle accidents, indicate the kind of vehicle(s) involved and the ownership of the vehicle, e.g., military or other. (c) Whether the injury was deliberately self-inflicted as an act of misconduct (injury self-inflicted to avoid duties) or as an act of mental instability (a suicide or attempted suicide), or was deliberately inflicted by another person, or accidentally incurred. (d) The place the injury occurred, e.g., location on post such as the barracks, dining hall, motor pool; if off post, location and status such as home on leave, in transit when absent without leave, etc. (e) The date the injury occurred. (f) Whether the military member was engaged in assigned duties and the nature of the duties. (2) An example of properly recorded cause of injury information is "Caused by rifle bullet; accidentally incurred when patient's rifle discharged while he was cleaning it in Barracks A, Fort Dix, NJ, 8 Jul 9X." (3) Additional information is needed for battle casualties. This information includes: whether the casualty was caused by enemy action, the kind of missile or

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agent causing the casualty, and the general geographic location of the patient at the time of injury. f. Item 34, Diagnoses/Operations and Special Procedures. (1) Recording ICD-9-CM codes. ICD-9-CM coding principles are outlined in lesson 2. An ICD-9-CM code should be recorded to the left of the diagnosis/operation entry to which it pertains. (2) Recording of diagnoses. Record all diagnoses that affect the current, uninterrupted period of treatment. Record and code unusual manifestations, e.g., scarlet fever with acute nephritis. Do not record the admitting or provisional diagnosis. Do not record diagnoses that relate to earlier admissions, or are status-post conditions, or physical findings which have no bearing on this period of treatment. (a) The principal diagnosis is the condition (diagnosis) established after study to be responsible for the admission of the patient to the hospital. The attending physician must confirm the principal diagnosis, and it must be substantiated by the documentation in the medical record. (b) The primary diagnosis is the condition (diagnosis) which is primarily responsible for using the greatest amount of hospital resources (it may or may not be the principal diagnosis). (c) Comorbidity is a preexisting condition that will cause an increase in length of stay in approximately 75 percent of cases, because of its presence with a specific diagnosis. (d) Complication is a condition arising during the hospital stay that prolongs the length of stay. (e) Diagnoses should be numbered consecutively as they are entered on each Inpatient Treatment Record Cover Sheet. The principal diagnosis will always be diagnosis number one. Indicate all conditions which are found to have been present during this period of treatment, even though established after death. Use the notation "Established Postmortem" as appropriate. List the specific drugs involved in an overdose case. (f) Cause of admission. The principal diagnosis, whether as a direct or transfer admission, should be considered the cause of admission and so recorded. A patient admitted in respiratory distress (later diagnosed as bronchopneumonia) who also has hypertension would have bronchopneumonia recorded as the cause of admission. In cases of several related conditions occurring simultaneously which require the patient's admission, the condition first in the chain of etiology should be designated as the cause of admission. For unrelated but simultaneously occurring conditions requiring admission, the most serious condition will be recorded as the cause of admission. In instances where two or more diagnoses could be selected due to the

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complexity of the case, the selection will be a matter of judgment. The cause of admission diagnosis should be the first diagnosis entry on the Inpatient Treatment Record Cover Sheet and coded in Field 38 of the Admission and Coding Form. (3) Recording of operations and special procedures. Date and record all operations and procedures performed during the current hospitalization, including those performed prior to transfer into your MTF. Record the principal procedure first, regardless of the date it was performed. Record only "exchange" and "intrauterine" transfusions in Item 34. (4) Residual disability. Leave this field blank. (5) Special information on death. For cases terminating in death, all conditions found to have been present during the period of treatment, even though established after death, must be recorded with the notation "Established postmortem," when appropriate. In cases of suicide, homicide, or death by legal execution, information characterizing the death will be included in addition to the required diagnostic data. (6) Deliveries. The mother's record should include the following: (a) Presentation of each fetus with indication of live birth or stillbirth except in case of a delivery by cesarean section. Terminology for recording presentation of fetus can be found in The Standard Nomenclature of Diseases and Operations . (b) Previous Cesarean section, if any. (c) Duration of pregnancy in weeks. (d) The cause of fetal death and birth weight in the case of a stillbirth. (7) Liveborn infants - additional information. A separate Inpatient Treatment Record is required for each infant born in the reporting MTF. Record the following on the ITRCS: (a) Whether the infant is a single birth or one of multiple births. If the latter, indicate also whether all mates were liveborn or if one or more were stillborn. (b) Gestational age and birth weight. Record birth weight in grams. (8) Drug overdoses. The Inpatient Treatment Record Cover Sheet on overdose cases must include all sufficient information to apply the coding principles outlined in Appendix A. (See principle IV Adverse Effects of Drug and E Codes.)

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g. Item 35, Total Days This Facility. This facility refers to the reporting facility (MTF), the MTF where the Inpatient Treatment Record Cover Sheet is being completed. (1) Item 35a, Absent Sick Days. (a) If the patient has absent sick days, record this information in Item 31. Absent sick days are the days an Army service member is an inpatient in a nonmilitary MTF. (b) If no absent sick days are recorded in Item 31, leave Item 35a blank. (2) Item 35b, Other Days . (a) Enter the number of days subsisting out in Item 35b. (b) Enter the number of days AWOL (10 days or less) in Item 35b. (c) Enter any other days not recorded in Items 35a, c, d, or e. (3) Item 35c, Convalescent Leave/Cooperative Care Days . (a) Enter convalescent leave/cooperative care days in 35c. (b) If there are no convalescent leave/cooperative care days, leave blank. (4) Item 35d, Supplemental Care Days . (a) Enter supplemental care days in 35d. (b) If there are no supplemental care days to report, leave blank. (5) Item 35e, Bed Days. (a) Enter in 35e only those days in which a patient occupies a bed or bassinet. (b) Days recorded in 35a, b, c, or d are not bed days. (6) Item 35f, Total Sick Days. (a) Enter the total of 35a, b, c, d, and e. (b) Count the day of admission but do not count the day of disposition in computing the total sick days. To double check the total number of days, subtract the day of admission from the day of disposition.

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(c) Carded for Record Only (CRO). Enter "0" in Item 35f only; Items 35a, b, c, d, and e should not have entries. h. Item 36, Total Days All Facilities. Used for transfer admissions only. The sources of data for this item is admission and disposition and the patient's ITR. (1) An ITRCS should be prepared each time a patient is transferred from one MTF to another. Item 36 is the summation of all transfer ITRCS. (2) For direct admissions, leave Item 36 blank. (3) For total days, include the following and compute using the date of initial admission and date of disposition. (a) Item 36a = the total absent sick days. (b) Item 36b = the total other days. (c) Item 36c = the total convalescent leave/cooperative care days. (d) Item 36d = the total supplemental care days. (e) Item 36e = the total bed days. (f) Item 36f = the total sick days (the summation of Items 36a, b, c, d, and e. This information should be taken from the date of initial admission recorded in Item 30 and from Item 31 of all ITRCSs received from other facilities. i. Automated MTFs. The completion of Items 35 and 36 are system-generated by AQCESS/CHCS. j. Signature of Attending Medical Officer. Typed signature blocks are required for the attending physician, dentist, podiatrist, midwife, and other authorized health care provider when in charge of a case. ITRCSs for CRO-DOA cases (when death is pronounced by other than military MTF) and for cases where the entire bed occupancy was in absent sick status require only the signature of the patient administrator or medical records officer. k. Signature of Medical Records Officer or Patient Administrator. Ensure that the signature of the patient administrator or medical records administrator is annotated. The medical records administrator or the patient administrator will sign each completed ITRCS, thereby certifying to an accurate transcription of the worksheet signed by the provider. Signature stamps are permitted for use by the medical records administrator or the patient administrator.

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3-6.

DOCUMENT FLOW OF INPATIENT TREATMENT RECORD COVER SHEET

a. Initial Preparation. The ITRCS must be initiated in the Admission and Disposition Office (AAD) when a patient is admitted, and Items 1 through 30 (except for Items 25 and 26) are completed. Nonautomated sites will use DA Form 2985 (Admission and Coding Information) as a source document. At automated sites, the ITRCS is computer-generated by the Automated Quality of Care Evaluation Support System (AQCESS) or the Composite Health Care System (CHCS). b. Initial Flow. Local procedures prescribe the flow of the ITRCS. In some Army hospitals, the AAD sends the original and three copies of the ITRCS, along with the Inpatient Treatment Record jacket and the Admission and Coding Form to the inpatient record area for filing in a suspense file pending disposition of the patient. In other hospitals, AAD maintains the suspense file on ITRCS and related forms until disposition of the patient. Still other hospitals send the ITRCS to the ward for filing until disposition of the patient. The worksheet copy (third copy) is always sent to the ward for use by the health care provider and filed in the patient's chart. c. Disposition Flow. When the patient is dispositioned, the worksheet copy of the ITRCS is completed and signed by the health care provider. This worksheet and other documents in the patient's chart are used to complete the other three copies of the ITRCS. The personnel in the Medical Records Administration Branch are responsible for reviewing the ITRCS for completeness and accuracy. The DA Form 2985 (Admission and Coding Information) is completed from the ITRCS. The copies of the completed ITRCS are then distributed in accordance with AR 40-66 and AR 40-400.

Continue with Lesson Exercises

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EXERCISES, LESSON 3 INSTRUCTIONS. Complete the following exercises by marking the lettered response that best matches the exercise, or by finishing the incomplete statement, or by writing the answer in the space provided at the end of the question. After you have completed the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers with the solutions.

1. What information is required in Item 33 of the Inpatient Treatment Record Cover Sheet when a patient is treated for an injury? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

2. An ITRCS is prepared as an original and three copies. What is the final distribution of the ITRCS? a. b. c. d. ______________________________. ______________________________. ______________________________. ______________________________.

3. When a patient has more than one operation and/or procedure, what sequence is used to record these multiple operations and/or procedures? ________________________________________________________________

4. What is the purpose of the Inpatient Treatment Record Cover Sheet? ________________________________________________________________ ________________________________________________________________ ________________________________________________________________

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5. Administrative information on convalescent leave is recorded in Item______ of the ITRCS. Then, at the time of disposition, the information on convalescent leave is used in completing Item ______. 6. How does the health care provider in charge of a case verify the diagnostic/operative information recorded in Item 34 of the Inpatient Treatment Record Cover Sheet? ________________________________________________________________

7. On the Inpatient Treatment Record Cover Sheet, Item 36, Total Days All Facilities, is used for direct admissions only. a. True. b. False.

8. Total bed days and total sick days are always equal. a. True. b. False.

9. Which Army regulation establishes the purpose and use of the Inpatient Treatment Record Cover Sheet? ________________________________________________________________

10. Who is responsible for preparation of the ITRCS and other administrative aspects of the ITRCS? ________________________________________________________________ 11. The format is the same for the two variations of the Inpatient Treatment Record Cover Sheet (ITRCS). What is the form number and two variations? a. b. ______________________________. ______________________________.

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12. Which medical treatment facilities are required to use the Inpatient Treatment Record Cover Sheet? ________________________________________________________________

13. Which copy of the Inpatient Treatment Record Cover Sheet is usually used and distributed as the worksheet? ________________________________________________________________

14. Nonautomated sites obtain data for items 1 through 30 (except Items 25 and 26) of the Inpatient Treatment Record Cover Sheet from what source? ________________________________________________________________

15. Name the three categories of patients for whom the Inpatient Treatment Record Cover Sheet is prepared. a. b. c. ______________________________. ______________________________. ______________________________.

16. Define the following abbreviations. a. b. c. d. e. f. g. h. PR: ___________________________. NB: ___________________________. ACH: __________________________. Abs Sk: ________________________. MEB: __________________________. SI: ____________________________. AMA: _____________________________. TDRL: ____________________________.

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Exercises 17 through 20 provide data about individual patients. For each patient, complete items 25, 26, and 31 through 36 (if applicable) on the ITRCS provided on the following pages. Use the codes listed below for the appropriate condition of each patient. • • • • • 4809 Viral Brochopneumonia 49390 Asthma Congestive Heart Failure Ulcer of Duodenum with Hemorrhage Chrondromalacia of patella

17. RAMEY, WILLIAM P. The patient was dead on arrival in the emergency room. The diagnosis CONGESTIVE HEART FAILURE (established postmortem) was determined by autopsy. 18. TINDALL, HOWARD W. On 8 Dec 9X, the patient was a transfer to the United States Army Hospital (USAH) at Fort Splendid. He had been placed on the VSI list on 27 Nov 9X, was upgraded to SI on 29 Nov 9X, and remained SI at the time of transfer. His diagnoses were (1) ULCER OF DUODENUM WITH HEMORRHAGE and (2) ACUTE NORMOCYTIC ANEMIA DUE TO BLOOD LOSS. The patient received two units of blood, and was returned to duty, 15 Dec 9X. 19. BIRCHETT, JOANN M. The patient was returned to duty 10 Dec 9X. During her hospitalization, she was treated for (1) VIRAL BRONCHOPNEUMONIA and (2) CHRONIC ASTHMA. The second diagnosis was previously recorded (PR: FAMC, Denver, CO, 15 Apr 8X). 20. KRAFT, CHRISTOPHER M. On 19 Nov 9X, the patient was a transfer to USAH, Fort Splendid. His diagnosis was CHONDROMALACIA OF (right) PATELLA. This condition existed prior to service (EPTS) and was previously recorded (PR: WRAMC, Washington, DC, 26 Sep 8X). On 20 Nov 9X, he was taken to surgery for a partial patellectomy. On 26 Nov 9X, a medical evaluation board (MEB) recommended referral to a physical evaluation board (PEB). On 30 Nov 9X, the PEB recommended TDRL. The patient was on convalescent leave 5 Dec 9X to 30 Dec 9X (25 days). On 31 Dec 9X, the patient was placed on TDRL (under provisions of AR 635-40).

Check Your Answers

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Figure 3-4. DA Form 3647 for Exercise 17.

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Figure 3-5. DA Form 3647 for Exercise 18.

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Figure 3-6. DA Form 3647 for Exercise 19.

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Figure 3-7. DA Form 3647 for Exercise 20.

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SOLUTIONS TO EXERCISES, LESSON 3 1. Circumstances; causative agent; whether injury was deliberately self-inflicted or inflicted by another person; place and date injury occurred, whether injury occurred during duty/nonduty; and nature of duty. (para 3-5e(1)(a) -- (f)) 2. a. b. c. d. Original to: Inpatient Treatment Record. Copy 1 to: Health Record/Outpatient Treatment Record. Copy 2 to: Register Number Index. Copy 3 (Worksheet Copy) placed after the original in the Inpatient Treatment Record. (para 3-2b(1) -- (5))

3. Principal procedure first, regardless of date, then in chronological sequence (para 3-5f(3)) 4. To serve as a medical and administrative summary of each case; an essential document for Health Record/Outpatient Treatment Record; a source document for medical statistical information, and a legal document for third party liability cases. (para 3-1a) 5. 31; 35c. (para 3-5c(3) and para 3-5g(3)) 6. Signature in appropriate block on ITRCS physician's worksheet copy. (para 3-4c) 7. b (para 3-5h) 8. b (para 3-5g(5)(b)) 9. AR 40-66. (para 3-1a) 10. Chief, Patient Administration Division and the health care provider. (para 3-1d) 11. a. DA Form 3647 for typed entries. b. DA Form 3647 for computer-generated continuous form printing. (para 3-4a(1), (2)) 12. All hospitals and convalescent centers. (para 3-1b) 13. The third (or last) copy. (para 3-2b(4)) 14. Admission and Coding Information (DA Form 2985). (para 3-5a) 15. a. All admissions as bed patients. b. Liveborn infants. c. Carded for Record Only (CROs) cases. (para 3-1c(1) -- (3))

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16. a. Previously recorded. b. Newborn. c. Army community hospital. d. Absent sick. e. Medical evaluation board. f. Seriously ill. g. Against medical advice. h. Temporary disability retirement list. (para 3-3b)

See next four pages for solutions for Exercises 17 through 20.

END OF LESSON 3

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Figure 3-8. DA Form 3647, Solution for Exercise 17.

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Figure 3-9. DA Form 3647, Solution for Exercise 18.

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Figure 3-10. DA Form 3647, Solution for Exercise 19.

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Figure 3-11. DA Form 3647, Solution for Exercise 20.

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LESSON ASSIGNMENT

LESSON 4 LESSON ASSIGNMENT LESSON OBJECTIVES

Individual Patient Data System. Paragraphs 4-1 through 4-109. After completing this lesson, you should be able to: 4-1. Identify the purposes of the Individual Patient Data System. 4-2. Given a completed Inpatient Treatment Record Cover Sheet, extract data for coding DA Form 2985 (Admission and Coding Information). 4-3. Define terms related to the Individual Patient Data System. 4-4. Identify forms used in the Individual Patient Data System. 4-5. List the transmittal procedures used in the Individual Patient Data System. 4-6. Identify data reduction procedures as it relates to the Individual Patient Data System. 4-7. Identify procedures to code DA Form 2985 (Admission and Coding Information) from DA Form 1380 (U.S. Field Medical Card).

SUGGESTION

After completing the assignment, complete the exercises of this lesson. These exercises will help you to achieve the lesson objectives.

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LESSON 4 INDIVIDUAL PATIENT DATA SYSTEM Section I. GENERAL 4-1. PURPOSE OF THE INDIVIDUAL PATIENT DATA SYSTEM

a. The Individual Patient Data System (IPDS) is a computer-oriented collection of demographic and medical data on inpatients treated by the Army Medical Department (AMEDD). Also included are other cases of sufficient interest that require reporting as carded for record only (CRO) and data on active duty Army personnel treated in an absent sick status in nonmilitary medical treatment facilities (MTFs). Authority and responsibility to operate the IPDS are prescribed in AR 40-400. b. The IPDS provides the following: (1) Data for planning, managing, and evaluating the AMEDD medical care system at Headquarters, Department of the Army (HQDA), major Army command (MACOM) headquarters, and individual MTF levels. (2) Data for medical and epidemiological research. (3) Rapid data retrieval in response to inquiries from HQDA, Medical Command (HSC), Office of The Surgeon General (OTSG), other DA components, Department of Defense (DOD), Congress, Federal agencies, and other authorized organizations and individuals. (4) Management reports and retrieval of special data for the hospital commander and his staff. 4-2. IPDS HANDBOOK

Information in this lesson is taken from the Individual Patient Data System (IPDS) User's Manual published by the Patient Administration Systems and Biostatistics Activity, U.S. Army Medical Department Center and School, Fort Sam Houston, Texas. The IPDS User's Manual contains detailed procedures and instructions for processing medical information extracted from inpatient treatment records into a prescribed format for the IPDS. It also provides a description of output reports produced by the IPDS. 4-3. EXPLANATION OF TERMS

There are terms associated with the Admissions and Dispositions (AAD) forms that will be used throughout this lesson. It will be to your advantage to become familiar with the following terms:

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a. Code. Numeric or alphabetic characters that are assigned to specific information in the prescribed IPDS format. EXAMPLE: Data Codes AB A10

Explanation Cardiology Clinic Active duty Army

b. Field. An area assigned to a particular category of information. Each field is assigned a sequential category number. Within the field are one or more separately numbered spaces referred to as columns. EXAMPLE: 1. REPORTING MTF is the field.

1. REPORTING MTF
1 2 3 4 5 6

A

c. Column. Each of the small blocks within a field is a column. EXAMPLE: Blocks 1-6 are columns.

1

2

3

4

5

6

A
d. Item. Refers to an entry on DA Form 3647 (Inpatient Treatment Record Cover Sheet). EXAMPLE: Item 1 on the cover sheet is the register number. 1. REGISTER NUMBER

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NOTE: Fields, columns, and items corresponding with these examples are found on DA Form 2985 (Admission and Coding Information) which initiates the documenting of medical information (see figure 4-1) and DA Form 3647 (see figure 4-2). 4-4. SOURCES OF DATA

a. DA Form 2985 (Admission and Coding Information) (see figure 4-1) is a dual purpose form used as a patient admission information document and coding transcript in Army MTFs not having automated admission and disposition/clinical records processing. Fields on the DA Form 2985 have been arranged so that most of the demographic and administrative data are on page 1 of the three-page form. This allows page 1 of the form to be completed in its entirety once disposition of the patient is made. Information on page one of the form is used to generate management reports. NOTE: DA Form 2985 is known as the A&C Form. b. The A&C Form is also designed so that most of the information needed to complete page 1 is derived from the patient interview at the time of admission. The remaining information must be obtained from the Inpatient Treatment Record Cover Sheet (ITRCS) (see figure 4-2) after the patient has been dispositioned. 4-5. PROCEDURES a. Nonautomated hospitals should complete applicable fields of the A&C Form in an original and two legible copies at the time of admission. b. Codes must be written legibly to avoid errors in data reduction. Alphabetical characters must be printed as capital block letters; these codes do not contain lower case letters. Zero must always be written Ø. The alphabetical characters "O," "S," "U," and "Z," must always be written as "O," "S," "U," and "Z." c. Maintain the original and legible copies of the A&C Form in a suspense file while the patient remains in an inpatient status. d. At the time of disposition, remove the original and legible copies of the A&C Form from the suspense file and complete the applicable fields on Page 1 of the form. e. Forward the A&C Form to the Medical Records Administration Branch for filing in the patient's terminal digit file folder to await completion of the Inpatient Treatment Record (ITR). f. Upon completion of the ITR, remove the A&C Forms from the patient's terminal digit file folder and complete pages 2 and 3 of the form. g. File the original A&C Form (DA Form 2985) in the patient's ITR.

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Figure 4-1. DA Form 2985 (Admission and Coding Information) (continued).

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Figure 4-1. DA Form 2985 (Admission and Coding Information) (continued).

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Figure 4-1. DA Form 2985 (Admission and Coding Information) (concluded).

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Figure 4-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet).

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h. Forward one legible copy of the A&C Form and the Inpatient Treatment Record Cover Sheet (DA Form 3647) (ITRCS) to The U.S. Army Medical Department Center and School, Patient Administration Systems and Biostatistics Activity (PASBA) for input into the IPDS data base only if your facility is a non-fixed MTF. i. Maintain one legible copy locally in a register number file with a copy of the related (ITRCS) for future reference. Section II. CODING OF DA FORM 2985 4-6. GENERAL

a. This section of the lesson will explain how patient information, (administrative and medical) is coded on the A&C Form (DA Form 2985) for entry into the Individual Patient Data System (IPDS) database. The instructions have been taken from the IPDS User's Manual. b. Instructions related to information obtained during the admission interview are covered in Subcourse MD0752 (lesson 1, Admission and Disposition). c. Information and examples in the following paragraphs have been taken from figures 4-1 and 4-2 for the purpose of leading you through the coding of each field or space on the DA Form 2985. 4-7. REPORTING MEDICAL TREATMENT FACILITY (MTF) (FIELD 1, COLUMNS 1 THROUGH 5) a. Source of data : Table of MTF codes (see table 4-1). b. An "A" for Army is printed in the first position (column 1) of the A&C Form. Find the code for your MTF in table 4-1 and enter it the next four columns (2-5) of field 1, Reporting MTF as shown below: EXAMPLE: 1. REPORTING MTF
1 2 3 4 5 6

A

1

4

1

1

c. Code 1411 is used for Darnell ACH, Fort Hood, TX.

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0101 Tripler AMC, Oahu, HI 0111 Bassett ACH, Fort Wainright, AK 0121 Gorgas ACH, Ancon, Panama 0211 USACH,SHAPE, Belgium 0311 USACH, Berlin, Germany 0321 USACH, Bremerhaven, Germany 0331 Frankfurt ARMC, Germany 0341 USACH, Heidelberg, Germany 0351 Landstuhl ARMC, Germany 0361 USACH, Nuernberg, Germany 0371 USACH, Bad Cannstatt, Germany 0381 USACH, Wuerzburg, Germany 0391 USACH, Augsburg, Germany 0421 USACH, Vicenza, Italy 0611 121stst Evac Hosp, Seoul, Korea 0711 USAMEDDAC, Camp Zama, Japan (AHC) 1001 Walter Reed AMC, Washington, DC 1011 USAMEDDAC (Wilcox AHC) Fort Drum, NY 1021 DeWitt ACH, Fort Belvoir, VA 1031 Womack ACH, Fort Bragg, NC 1041 Cutler ACH, Fort Belvior, MA 1051 Walson ACH, Fort Dix, NJ 1061 McDonald ACH, Fort Eustis, VA 1071 Ireland ACH, Fort Knox, KY 1081 Kenner ACH, Fort lee, VA 1091 Kimbrough ACH, Fort Meade, Md

1111 Patterson ACH, Fort Monmouth, NJ 1121 Keller ACH, West Point, NY 1131 Hawley ACH, Fort Harrison, IN 1201 Fitzsimons AMC, Denver, CO 1211 Evans ACH, Fort Carson, CO 1221 Munson ACH, Fort Leavenworth, KS 1231 General Leonard Wood ACH, Fort Leonard Wood, MO 1241 Irwin ACH, Fort Riley, KS 1251 USAHC, Fort Sheridan, IL 1301 Eisenhower AMC, Fort Gordon, GA 1311 Martin ACH, Fort Benning, GA 1321 Blanchfield ACH, Fort Campbell, KY 1331 Moncrief ACH, Fort Jackson, SC 1341 Noble ACH, Fort McClellan, AL 1351 Fox ACH, Redston Arsenal, AL 1361 Lyster ACH, Fort Rucker, AL 1371 Winn ACH, Fort Stewart, GA 1401 Brooke AMC, Fort Sam Houston, TX 1411 Darnell ACH, Fort Hood, TX 1421 Bayne-Jones ACH, Fort Polk, LA 1431 Reynolds ACH, Fort Sill, OK 1501 William Beaumont AMC, Fort Bliss, TX 1511 Bliss ACH, Fort Huachuca, AZ 1601 Letterman AMC, San Francisco, CA 1611 Silas B. Hays ACH, Fort Ord, CA 1631 Weed ACH, Fort Irwin, CA 1701 Madigan AMC, Fort Lewis, WA

Table 4-1. Medical treatment facility (MTF) codes. NOTE: The field in the above example, and the fields in other examples to follow in this explanation, are enlarged fields of DA Form 2985. These and other codes will be used for fictitious facilities, administrative and medical conditions, patients, and personnel for instructional purposes only. Some information on DA Form 2985 will not require coding, but must be verified as correct by comparison with the Inpatient Treatment Record Cover Sheet (ITRCS). d. The MTF codes listed above as well as Table of Organization and Equipment (TOE) Hospital codes are listed in the Individual Patient Data System (IPDS) User's Manual. Any codes not listed in that document will be assigned by PASBA. Point of contact is Chief, Medical Summary Branch, Biostatistics Division, DSN 471-5579.

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4-10

4-8.

MTF LOCATION (FIELD 2, COLUMNS 7 THROUGH 8) a. Source of data. Table of MTF state location codes (see table 4-2).

| Alabama | Alaska | Arizona | Arkansas | California | Colorado | Connecticut | Delaware | District of Columbia | Florida I Georgia | Hawaii I Idaho | Illinois | Indiana | Iowa | Kansas | Kentucky | Louisiana | Maine | Maryland | Massachusetts | Michigan | Minnesota | Mississippi | Missouri

Ø1 Ø2 Ø4 Ø5 Ø6 Ø8 Ø9 1Ø 11 12 13 15 16 17 18 19 2Ø 21 22 23 24 25 26 27 28 29

Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

3Ø 31 32 33 34 35 36 37 38 39 4Ø 41 42 44 45 46 47 48 49 5Ø 51 53 54 55 56

Table 4-2. State location codes. b. Enter your MTF's state location code from table 4-2. State location codes, as well as overseas country location codes are listed in the Individual Patient Data System (IPDS) User's Manual. For TOE units, this is the deployment site, not the garrison location. EXAMPLE: 2. MTF LOCATION 7 8
(State or Country Code)

4

8

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4-11

4-9.

REGISTER NUMBER (FIELD 3, COLUMNS 9 THROUGH 15)

a. Source of data. Assigned by AAD office at nonautomated sites. Assigned by the Automated Quality of Care Evaluation Support System (AQCESS)/Composite Health Care System (CHCS) at automated sites. (Item 1, ITRCS). b. The register number should contain seven numbers. If not, zero fill to the left. EXAMPLE: 3. REGISTER NUMBER
9 10 11 12 13 14 15

Ø
4-10. NAME

1

7 6 5 5

Ø

a. Source of data. Admission interview or the identification (ID) card. (Item 2, ITRCS). b. Enter the patient's name (last, first, middle initial). Include all initials for North Atlantic Treaty Organization (NATO) patients. Enter the maiden name for maternity patients. EXAMPLE: NAME (Last, First, Middle Initial)

DALLAS, KENNETH N.

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4-12

4-11. PAY GRADE (FIELD 4, COLUMNS 16 THROUGH 17) a. Source of data. Admission interview or the ID card. (Item 3, ITRCS). b. Enter the patient's pay grade as of the day of admission to your MTF. Use table 4-3 for military members of all components, including foreign military members and retirees of U.S. uniformed services. For nonmilitary patients, leave this field blank. EXAMPLE: 4. PAY GRADE 16 17

PVT

E
ARMY GENERAL OF THE ARMY (GA) GENERAL (GEN) LIEUTENANT GENERAL (LTG) AJOR GENERAL (MG) BRIGADIER GENERAL (BG) COLONEL (COL) LIEUTENANT COLONEL (LTC) MAJOR (MAJ) CAPTAIN (CPT) FIRST LIEUTENANT (1LT)

1
COAST GUARD FLEET ADMIRAL (FADM) ADMIRAL (ADM) VICE ADMIRAL (VADM) AIR FORCE GENERAL OF THE AIR FORCE Gen AF) GENERAL (GEN) LIEUTENANT GENERAL (LTG) MAJOR ENERAL (MG) BRIGADIER GENERAL (BG) COLONEL (COL) LIEUTENANT COLONEL (LTC) MAJOR (MAJ) CAPTAIN (CPT) FIRST LIEUTENANT (1st Lt) DATA CODES 11

NAVY/ MARINES GENERAL OF THE MARINES (GA) GENERAL MARINES (GEN) LIEUTENANT GENERAL (LTG) MAJOR GENERAL (Maj Gen) BRIGADIER GENERAL (BG) COLONEL (Col) LIEUTENANT COLONEL (Lt Col) MAJOR (Maj) CAPTAIN (Capt) FIRST LIEUTENANT (1st Lt)

10 09

REAR ADMIRAL (RADM) COMMODORE (COMO) CAPTAIN (CAPT) COMMANDER (CDR)

08

07 06 O5

LIEUTENANT COMMANDER (LCDR) LIEUTENANT (LT) LIEUTENANT JUNIOR GRADE (LTJG)

O4 O3 O2

Table 4-3. Grade codes (continued).

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4-13

ARMY SECOND LIEUTENANT (2LT) CHIEF WARRANT OFFICER (CWO4) CHIEF WARRANT OFFICER (CWO3) CHIEF WARRANT OFFICER (CWO2) WARRANT OFFICER (WO1) SERGEANT MAJOR OF THE ARMY (SMA) COMMAND SERGEANT MAJOR (CMS) STAFF SERGEANT MAJOR (SSM) FIRST SERGEANT (1SG) MASTER SERGEANT (MSG) PLATOON SERGEANT (PSG) Or SERGEANT FIRST CLASS (SFC) STAFF SERGEANT (SSG) SERGEANT (SGT) CORPORAL (CPL)

NAVY/ MARINES SECOND LIEUTENANT (2LT) CHIEF WARRANT OFFICER (CWO4) CHIEF WARRANT OFFICER (CWO3) CHIEF WARRANT OFFICER (CWO2) WARRANT OFFICER (WO1) SERGEANT MAJOR OF THE MARINE CORPS (Sgt Maj) SERGEANT MAJOR (Sgt Maj) MASTER GUNNERY SERGEANT (MGy Sgt) FIRST SERGEANT (1st Sgt) MASTER SERGEANT (MSgt) GUNNERY ERGEANT (Gy Sgt)

COAST GUARD ENSIGN (ENS)

AIR FORCE SECONDLIEUTENAN T (2LT) CHIEF WARRANT OFFICER (CWO4) CHIEF WARRANT OFFICER (CWO3) CHIEF WARRANT OFFICER (CWO2) WARRANT OFFICER (WO1) CHIEF MASTER THE AIR FORCE (CMSgtAF) CHIEF MASTER SERGEANT (CMSgt) ____

DATA CODES O1

CHIEF WARRANT OFFICER (WO4) CHIEF WARRANT OFFICER (WO3) CHIEF WARRANT OFFICER (WO2) WARRANT OFFICER (WO1) MASTER CHIEF PETTY OFFICER OF THE NAVY (MCPON) MASTER CHIEF PETTY OFFICER (MCPO) ____

W4 W3

W2

W1

E9

E9

E9

SENIOR CHIEF PETTY OFFICER (SCPO) ____ CHIEF PETTY OFFICER (CPO)

SENIOR MASTER SERGEANT (SMSgt) ____ MASTER SERGEANT (MSgt)

E8

E8 E7

STAFF SERGEANT (SSgt) SERGEANT (Sgt) CORPORAL (Cpl)

PETTY OFFICER FIRST CLASS (PO1) PETTY OFFICER (PO2) PETTY OFFICER THIRD CLASS (PO3) ____

TECHNICAL SERGEANT (TSgt) STAFF SERGEANT (SSgt) SERGEANT (Sgt)

E6

E5

E4

SPECIALIST (SPC)

____

____

E4

Table 4-3. Grade codes (continued).

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4-14

ARMY

NAVY/ MARINES LANCE CORPORAL (LCpl) PRIVATE FIRST CLASS (PFC) PRIVATE (PVT)

COAST GUARD

AIR FORCE

DATA CODES E3

PRIVATE FIRST CLASS (PFC) PRIVATE (PV2) PRIVATE (PVT)

SEAMAN (Seaman) SEAMAN APPRENTICE (SA) SEAMAN RECRUIT (SR)

SENIOR AIRMAN (SrA) AIRMAN FIRST (A1C) AIRMAN BASIC (Amn)

E2 E1 CD

CADET (Includes cadets of the uniformed services academies and ROTC cadets) UNKNOWN (Not to be used for U.S. Army active duty personnel, Army Reserve/National Guard, USMA cadets)

ZZ

Table 4-3. Grade codes (concluded). 4-12. SEX (FIELD 5, COLUMN 18) a. Source of data. Admission interview or ID card. (Item 4, ITRCS). b. The MTF must make a choice in uncertain cases as in extreme deterioration of remains in which a pathologist cannot make a determination. c. Select sex code from table 4-4. EXAMPLE: 5. SEX 18

M
DATA Male Female Table 4-4. Sex codes. CODE M F

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4-15

4-13. DATE OF BIRTH (FIELD 6, COLUMNS 19 THROUGH 26) a. Source of data. Admission interview or ID card. b. Enter in succession, four digits for year of birth; two digits for birth month (Ø-12); and two digits for day of birth (Ø1-31). EXAMPLE: 6. DATE OF BIRTH (YYYYMMDD) 19 20 21 22 23 24 25 26

1

9

7

X

Ø

4

1

3

4-14. AGE AT ADMISSION (FIELD 7, COLUMNS 27 THROUGH 29) a. Source of data. Admission interview. For live births at your MTF and transferred live births less than 24 hours old, enter ØØD. This is calculated by AQCESS/CHCS from field 6, Date of Birth, and field 26, Date of This Admission. (Item 5, ITRCS). b. Enter the patient's age in completed days, months, or years at the time of this admission to your MTF. For an infant delivered in a military MTF, enter data code ØØD from table 4-5 and NB. For an infant born outside your facility (e.g., enroute to the MTF), enter ØØD. For other infants under 1 month old, enter the age in days (e.g., 18D). For a child 1 month but less than 12 months old, enter the age in completed months (e.g., Ø2M). If a patient is 1 year or older, enter the age in completed years. The code 99Y will be used for patients 99 years old and older. NOTE: If patient is between 1 and 9 years, enter Ø in column 27 to fill the field. EXAMPLES: 7. 27 AGE AT ADMISSION 28 29

1

8

Y

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4-16

7. AGE AT ADMISSION 27 28 29

NB

Ø Ø D
DESCRIPTION Live-born infant Less than 1 day One day to less than 1 month One month to less than 12 months Patient's age in years, 1 year to 99 years Patient's age is more than 99 years Table 4-5. Age codes. 4-15. RACE (FIELD 8, COLUMN 30) a. Source of data. Admission interview. (Item 6, ITRCS). b. Enter the appropriate code from table 4-6. EXAMPLE 8. RACE 30 DATA CODES ØØD ØØD Ø1D-3ØD Ø1M-11M 99Y 99Y

C
DESCRIPTION Caucasoid (White) Negroid (Black) Mongoloid (Yellow) Western Hemisphere Indians (Red) Other Unknown Table 4-6. Race codes. NOTE: Do not use unknown (Z) for U.S. Army active duty personnel, Reserve/National Guard or USMA cadets. DATA CODES C N M R X Z

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4-17

4-16. ETHNIC BACKGROUND (FIELD 9, COLUMN 31) a. Source of data. Admission interview. b. Enter the appropriate data code and abbreviation from table 4-7. This is a required field for all patients. The code z may be used for other than active duty personnel. EXAMPLE: 9. ETHNIC BACKGROUND 31

OTHER

9
DESCRIPTION Hispanic SE Asian Filipino Other Asian/Pacific Islander Other Unknown ABBREVIATION Hisp Se Asi Filip Oth A/P Oth Unk DATA CODE 1 2 3 4 9 z

Table 4-7. Ethnic background codes. NOTE: Do not use unknown (Z) for U.S. Army active duty personnel, Reserve/National Guard, or USMA cadets. 4-17. RELIGION a. Source of data. Admission interview. (Item 7, ITRCS). b. Enter the abbreviation for the patient's religious preference from table 4-8. Leave blank for CRO cases.

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4-18

c. Table 4-8 is a partial list of religions. See AR 18-12-4 for a complete list. EXAMPLE: RELIGION

ROMAN-CATH

4-18. LENGTH OF SERVICE (FIELD 10, COLUMNS 32 THROUGH 34) a. Source of data. Admission interview. (Item 8, ITRCS). b. Enter the total length of all active duty service, even if interrupted, as of this admission for U.S. military personnel, foreign military personnel, and uniformed services military academy (USMA) cadets. c. Show service as follows: (1) Less than 1 month, record in days (e.g., 12 DYS on ITRCS will have data code 12D on A&C Form). DESCRIPTION No Religious Preference (none) Adventist, Seventh-Day Assemblies of God Baptist-American/Baptist Convention Baptist-Southern/Baptist Convention Baptist-Other Groups Brethren/Dunkers Buddhism Christian Science Church Of Christ Church of God Congregational Christian Disciples of Christ Episcopal/Anglican Evangelical, United Brethren Evangelican and Reformed Friends/Quaker Jehovah's Witnesses Table 4-8. Religion abbreviations (continued). DATA CODE NO-REL-PREF ADV-SEV-DAY ASBY-GOD AMER-BAPT SO-BAPT BAPT-OTHER BRETH BUD CHR-SCI CH-CHR CH-GOD CONG-CHR DIS-CHR EPISC EVANG-U-BRETH EVANG-REFMD FRIENDS JEH-WIT

MD0753

4-19

DESCRIPTION Jewish Latter Day Saints/Mormon Lutheran (excludes Lutheran, Missouri Synod) Lutheran Missouri Synod Methodist (includes Evangelical United Brethren) Evangelical Convenant Muslim Nazarene Orthodox Orthodox-Russian Pentecostal Presbyterian Reformed Roman Catholic Salvation Army Unitarian Universalist United Church of Christ (excludes Congregational Christian and Evangelical and Reformed) Protestant-other churches Protestant-no denominational preference Other religions Unknown

DATA CODE JEWISH LAT-DAY-ST LUTH LUTH-MO METH EVANG-COV MUSLIM NAZ ORTH ORTH-RUSS PENT PRESBY REFMD ROMAN-CATH SAL-ARMY UNITN-UNIV U-CH-CHR PROT-OTHER PROT-NO- DENOM OTHER-REL UNK

Table 4-8. Religion abbreviations (concluded). (2) Less than 1 year, record in months using completed months (e.g., 11 MOS on the ITRCS will have data code 11M on A&C Form). (3) From 1 year to 40 years, record in years using completed years (e.g., service of 18 years and 9 months would have 18 YRS on ITRCS and data code 18Y on A&C Form). d. Enter the appropriate code from table 4-9. If days, months, or years of service are less than 10, enter Ø in column 32. This is a required field for active duty. For all other patients, leave this field blank. EXAMPLE: 10. LENGTH OF SERVICE 32 33 34

2 MOS

Ø

2

M

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4-20

DESCRIPTION Entry on AD to 30 days One month AD, but less than 12 Twelve months to 40 years AD Unknown Table 4-9. Length of service codes.

DATA CODE ØØD-3ØD Ø1M-11M Ø1Y-4ØY ZZZ

NOTE: Do not use unknown (ZZZ) for AD U.S. Army, Navy, Marine Corps, Air Force, Reserve/National Guard or USMA cadets. 4-19. EXPIRATION OF TERM OF SERVICE (ETS) a. Source of data. Admission interview. (Item 9, ITRCS). b. Enter the date of ETS for military patients or the expiration date of Department of Defense (DD) Form 1173, Uniformed Services Identification and Privilege Card for dependent family members. For all other patients, leave this field blank. EXAMPLE: ETS

17 NOV 9X

4-20. FAMILY MEMBER PREFIX (FMP) (FIELD 11, COLUMNS 35 THROUGH 36) a. Source of data. Admission interview. (Item 11, ITRCS). b. Enter the family member prefix (FMP) from table 4-10. This is a required field for all patients and may not be zero-filled. c. An eligible spouse (or eligible former spouse) and children are given an FMP in the order that they become the sponsor's dependents. The sponsor's children include those preadopted, adopted, legitimate, illegitimate, and stepchildren. d. If a sponsor remarries, the new spouse takes the next higher number in the thirty series; i.e., the first spouse is coded 3Ø and the second spouse is coded 31. A former spouse eligible to deliver in a military MTF is coded in the 3Ø series, and the newborn child is coded as beneficiary authorized by statute (9Ø-95).

MD0753

4-21

e. Former female service members eligible to deliver in a military MTF should be coded as 2Ø, and the newborn child should be coded from the 9Ø-95 category. Multiple births, belonging in this category, should be assigned 9Ø for the first, 91 for the second, and so on. f. The child of an unwed daughter of the sponsor is coded in the 9Ø-95 category, unless the sponsor has adopted the child. EXAMPLE: 11. FMP 35 36

2
DESCRIPTION

Ø
DATA CODES Ø1-19 2Ø 3Ø -39 4Ø 45 5Ø 55 6Ø-69 9Ø-95 98 99

Children (Oldest, Next Oldest, etc.) Sponsor (Prime Beneficiary) Spouse & Former Spouses Mother or Stepmother Father or Stepfather Mother-in-Law Father-in-Law Other Authorized Dependents Beneficiary Authorized by Statute Civilian Emergencies All Others, Not Elsewhere Classified Table 4-10. Family member prefix (FMP) codes.

4-21. SOCIAL SECURITY NUMBER (SSN) (FIELD 12, COLUMNS 37 THROUGH 45) a. Source of data. Admission interview or ID card. (Item 12, ITRCS). b. Enter the SSN of the sponsor (active duty or retired service member, deceased service member, reserve component service member, or other prime beneficiary). c. The sponsor's SSN will be used, with the appropriate family member prefix, for identification of dependent family members, and all former spouses. When both parents are active duty, children will be identified by the SSN of the mother. All newborns will utilize the same SSN as coded on the mother's record.

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4-22

EXAMPLE: 12. SOCIAL SECURITY NUMBER 37 38 39 40 41 42 43 44 45

5

3

2

2

5

8

3

1

Ø

d. If the patient does not have an SSN, a pseudo-SSN will be constructed based on the patient's date of birth using the following convention: 80 + 0-9, and the year, month, and day (YYMMDD) of the patient's birth. The third digit (0-9) is used for sequencing of multiple same birth date admissions. The patient in the example below is the second admission with a birth date of 25 December 1969. EXAMPLE: 12. SOCIAL SECURITY NUMBER 37 38 39 40 41 42 43 44 45

8
4-22. ORGANIZATION

Ø

1

6

9

1

2

2

5

a. Source of data. Admission interview. (Item 13, ITRCS). b. Enter the active duty military patient's unit of assignment at the time of initial admission or when CRO. Enter the next higher echelon of command only when the designation of the unit is common to several organizations. Enter the unit and country for foreign military patients. EXAMPLE: ORGANIZATION (Active Duty Only)

9 FLD HOSP FORT SAM HOUSTON, TX

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4-23

4-23. MARITAL STATUS (FIELD 13, COLUMN 46) a. Source of data. Admission interview. b. Enter the appropriate marital status data code from table 4-11. Use the abbreviations in this table in the open space provided in field 13. This is a required field for all patients. EXAMPLE: 13. MARITAL STATUS 46

M

DESCRIPTION Annulled Divorced Interlocutory Legally Separated Married Single, Never Married Widowed Unknown

ABBREVIATION Ann Div Inter Sep Marr Sing Wid Unk Table 4-11. Marital status codes.

DATA CODE A D I L M S W Z

4-24. HOUR OF ADMISSION a. Source of data. Self-explanatory. (Item 22, ITRCS). b. Using the 2400-hour system enter the exact time the patient is admitted. For newborns, enter the time of birth. EXAMPLE: HOUR OF ADMISSION

Ø85Ø

MD0753

4-24

4-25. BRANCH/CORPS a. Source of data. Admission interview. (Item 18, ITRCS). b. Enter branch of service (Army, Navy, etc.) for enlisted personnel and other service officers. Enter corps (MC, MS, IN, etc.) for active or retired Army officers. Leave this area blank for all others. EXAMPLES: BRANCH/CORPS

ARMY
BRANCH/CORPS BRANCH/CORPS

MS

4-26. FLYING STATUS (FIELD 14, COLUMNS 47 THROUGH 49) a. Source of data. Admission interview. (Item 15, ITRCS) b. For military patients on flying status, code Y for yes. For military patients not on flying status, code N for no. Leave columns 48 and 49 blank. c. For all other patients, leave this field blank. EXAMPLE: 14. FLYING STATUS 47 48 49

N

MD0753

4-25

4-27. BENEFICIARY CATEGORY (FIELD 15, COLUMNS 50 THROUGH 52) a. Source of data. Admission interview. (Item 17, ITRCS). b. For U.S. Uniformed Services personnel (active or retired), enter the applicable category from table 4-12 in the open space provided. When applicable, include "T" to indicate AD for training or "I" to indicate inactive duty for training. UNIFORMED SERVICE Army (includes retired as well as Reserve and National Guard on extended AD) Army Reserve Initial AD for Training Other U.S. Army Reserve Other Army National Guard U.S. Navy U.S. Marine Corps U.S. Air Force U.S. Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration U.S. Military Academy Cadets U.S. Air Force Academy Cadets U.S. Naval Academy Midshipmen Reserve Officers Training Corps ABBREVIATION

ARMY IADT USAR ARNG USN USMC USAF USCG PHS NOAA USMA USAFA USNA ROTC

Table 4-12. Categories of Uniformed Services Personnel. c. For civilian employees of Federal agencies, indicate the Federal department (i.e., Army, Navy, State, Health and Human Services, Justice, Commerce, Labor, Treasury). d. For foreign military personnel, indicate the nation and armed forces with which the patient is serving; such as Federal Republic of Germany, Army. e. For all other personnel, leave the open space blank (no written description). f. Enter the appropriate data code from table 4-13.

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4-26

EXAMPLE: 15. BENEFICIARY CATEGORY 50 51 52

ARMY

A

1

1

NOTE: Item 17, ITRCS will list the branch of service from which a patient was retired. Item 13, ITRCS will list how the patient retired, (i.e., TDRL, PDRL, LENGTH OF SERVICE). DESCRIPTION Military Extended Active Duty: (over 60 days) Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration AD Recruits: (less than 60 days) Army Navy Marine Corps Air Force Coast Guard DATA CODES

A11 N11 M11 F11 C11 P11 B11

A13 N13 M13 F13 C13

Table 4-13. Department/type of beneficiary codes (continued).

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4-27

DESCRIPTION Reserves: Army AD IDT Navy AD IDT Marine Corps AD IDT Air Force AD IDT Coast Guard AD IDT U.S. Public Health Service AD IDT National Guard: Army AD IDT Air Force AD IDT Cadets: USMA, West Point, NY USNA, Annapolis, MD USAFA, Colorado Springs, CO USCGA, New London, CT Army ROTC Cadet Navy ROTC Cadet Air Force ROTC Cadet Other Applicant/Registrant: Army Navy Marine Corps Air Force

DATA CODES

A12 A22 N12 N22 M12 M22 F12 F22 C12 C22 P12 P22

A15 A25 F12 23

A14 N14 F14 C14 A21 N21 F21

A26 N26 M26 F26

Table 4-13. Department/type of beneficiary codes (continued).

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4-28

DESCRIPTION

DATA CODES

Former Service Members-Maternity Care Only: Army Navy Marine Corps Air Force Coast Guard Newborns of Former Service Members: Army Navy Marine Corps Air Force Coast Guard Retirees Length of Service: Army Navy Marine Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration U.S. Uniiformed Services Personnel on Permanent Disability Retired List (PDRL): Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration

A27 N27 M27 F27 C27

A28 N28 M28 F28 C28

A31 N31 M31 F31 V31 P31 B31

A32 N32 M32 F32 C32 P32 B32

Table 4-13. Department/type of beneficiary codes (continued).

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4-29

DESCRIPTION U.S. Uniformed Services Personnel on Temporary Disability Retired List (TDRL): Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration Dependents Dependents of AD Uniformed Services Personnel: (Excludes Former Spouses) Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration Dependents of Retired U.S. Uniformed Services Personnel: (Excludes Former Spouses) Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration

DATA CODES

A33 N33 M33 F33 C33 P33 B33

A41 N41 M41 F41 C41 P41 B41

A43 N43 M43 F43 C43 P43 B43

Table 4-13. Department/type of beneficiary codes (continued).

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4-30

DESCRIPTION

DATA CODES

Dependents of Deceased U.S. Uniformed Services Personnel: (Excludes Former Spouses) Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration Dependents of Deceased Retired Personnel: (Excludes Former Spouses) Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration Unremarried Former Spouse: Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration Dependents of Unremarried Former Spouse: Army Navy Marine Corps Air Force Coast Guard U.S. Public Health Service National Oceanic and Atmospheric Administration

A45 N45 M45 F45 C45 P45 B45

A47 N47 M47 F47 C47 P47 B47

A48 N48 M48 F48 C48 P48 B48

A49 N49 M49 F49 C49 P49 B49

Table 4-13. Department/type of beneficiary codes (continued).

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4-31

DESCRIPTION U.S. Civilian Employees/Dependents: State Department Employee-Overseas State Department Dependent-Overseas Other Federal Agencies/Department Employee Other Federal Agencies/Department Dependent DOD Remote Area Employee-CONUS DOD Remote Area Dependent-CONUS DOD Occupational Health Disability Retirement Examination Other Other Beneficiaries of U.S. Government: Veterans Administration (VA) Office of Worker's Compensation (OWCP) Service Home-Other Than Military Retiree Other Federal Agencies/Departments Contract Employee Federal Prisoner American Indian, Aleutian, Eskimo Micronesian, Samoan, Trust Territories Other Foreign Nationals/Dependents: IMET/SALES NATO Military NATO Dependent Non-NATO Military Non-NATO Dependent Foreign Civilian Foreign Civilian Dependent Prisoner of War/Internees Other Defense Department Designee: Secretary of Defense Secretary of Army Secretary of Navy Secretary of Air Force

DATA CODES

K51 K52 K53 K54 K55 K56 K57 K58 K59

K61 K62 K63 K64 K65 K66 K67 K68 K69

K71 K72 K73 K74 K75 K76 K77 K78 K79

K81 K82 K83 K84

Table 4-13. Department/type of beneficiary codes (continued).

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4-32

DESCRIPTION Civilian, No Government Connection: Humanitarian Emergency Patient Not Elsewhere Classified: (Includes newborn of dependent daughter)

DATA CODES

K91 K92

K99

Table 4-13. Department/type of beneficiary codes (concluded). 4-28. ZIP CODE OF RESIDENCE (FIELD 16, COLUMNS 53 THROUGH 61) a. Source of data. Admission interview. (Item 19, ITRCS). b. Enter the nine-digit zip code of the patient's residence in continental United States (CONUS). If the last four digits are unknown, zero-fill these positions. Outside continental United States (OCONUS), the Army post office (APO) or fleet post office (FPO) should be used. c. This is a required field for all inpatient, CRO, and absent sick records. If the zip code of residence is unknown, use the zip code of the MTF. EXAMPLE: 16. ZIP CODE OF RESIDENCE 53 54 55 56 57 58 59 60 6 1

7

8

2

3 4

6 1 Ø Ø

4-29. UNIT LOCATION (FIELD 17, COLUMNS 62 THROUGH 63) a. Source of data. Admission interview. b. Enter the state or country code of AD patient's unit of assignment. Select the state code from table 4-2. State codes, as well as overseas country location codes are listed in the Individual Patient Data System (IPDS) User's Manual.

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c. For units operating outside of their home station, this is the deployed location of operation. For soldiers not deployed with their unit, use the home base location. For patients enroute to a permanent change of station (PCS), use the code of their last unit of assignment. d. This is a required field for AD, Reserve/National Guard, and USMA Cadets. EXAMPLE: 17. UNIT LOCATION (State or Country Code) 62 63

TEXAS

4

8

4-30. MILITARY OCCUPATIONAL SPECIALTY (MOS) CODE (FIELD 18, COLUMNS 64 THROUGH 70). a. Source of data. Admission interview. b. This field is for AD only. This is a required field for U.S. AD and Reserve/National Guard personnel on active duty. c. Enter the MOS code from the list of codes in Appendix F. Some codes for U.S. Army occupational specialties are listed in this subcourse. A complete list for all branches of military service can be found in the Individual Patient Data System (IPDS) User's Manual. d. This field is left-justified; do not zero-fill. EXAMPLE: 18. MOS 64 65

FOOD SVC SPEC
66 67 68 69 70

9

4

B

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4-31. TRAUMA (FIELD 19, COLUMN 71) a. Source of data. Injury diagnosis, item 20 (type case), and item 33 (cause of injury), ITRCS. b. Enter a trauma code in field 19 from table 4-14. c. A cause of injury code must be entered in field 35, and at least one of the eight diagnostic fields must reflect an International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) injury diagnosis code from the 800 or 900 series, E930-E949, V71.3-V71.6, or 692.71. EXAMPLE: 19. TRAUMA 71

3
DESCRIPTION Battle Wound or Injury Direct Result of Action By or Against an Organized Enemy (declared war only) Other Battle Casualties Intentionally Inflicted Nonbattle Injury Result of Intervention of Legal Authority Assault or Intentionally Inflicted By Another Person Intentionally Self-Inflicted Accidental Injury (use codes 5-8 for AD only) Occurring While Off Duty (Includes leave, pass, absent without leave (AWOL), and other off-duty Schemes (Maneuvers) and Exercises All Other Scheduled Training (Including basic training, assault courses, etc) Occurring While On Duty (Except as in 6 and 7 above) Unknown Whether On or Off-Duty and Nonmilitary Injuries (use for all patients) Table 4-14. Trauma codes. DATA CODES

Ø 1

2 3 4

5 6 7 8 9

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4-32. PREVIOUS ADMISSION a. Source of data. Admission interview. (Item 10, ITRCS). b. Check "No" if the patient has not been admitted to your facility before. This entry is to indicate existence of a record of previous treatment in your MTF. Enter the year of previous admission if the patient has been admitted to your MTF whether for the same condition or for any other condition. EXAMPLE: PREV ADMISSION YEAR _ NO

4-33. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION (FIELD 20, COLUMN 72) a. Source of data. Admission interview or ID card. Item 21, ITRCS for transfers. b. Enter "Dir" for direct admission from other than the emergency room. c. Enter "Dir-ER" for direct admission from the ER. d. Enter "Trnsf" when the patient has been transferred from any other facility. e. Enter "CRO" for carded for record only cases. f. Enter "NB" for liveborn infants delivered in your MTF. g. Include the applicable authority for admission paragraphs from AR 40-3. h. Select the appropriate data code from table 4-15.

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EXAMPLE: 20. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION 72

DIR FROM ER AR 4Ø-3 PARA 4-1

Ø
DESCRIPTION Direct to Military Hospital from ER Direct to military hospital from other than ER AD direct to non-U.S. Armed Services hospital never transferred to military hospital Initial admission in non-U.S. Armed Services hospital, transferred to militay 9 AD only) Initial admission to non-U.S. Armed Services hospital, moved to military hospital (non-AD only) Transfer from U.S. Army hospital Transfer from U.S. Navy hospital Transfer from U.S. Air Force hospital Live birth in this hospital CRO Table 4-15. Source of admission. DATA CODES Ø 1 3 4 5 6 7 8 L C

4-34. WARD a. Source of data. Designated by care provider/physician. b. Enter the ward or nursing unit to which the patient was admitted. Leave blank for CRO cases. Enter "Abs Sk" for AD patients never transferred to a military hospital and whose entire period of hospitalization was in a non-U.S. Armed Services hospital.

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EXAMPLES: WARD

12B

WARD

ABS SK

4-35. EMERGENCY ADDRESSEE a. Source of data. Admission intervew. (Items 24, 27, and 29, ITRCS). b. Enter information relating to emergency addressee. Leave blank for CRO cases. EXAMPLE: NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

JOHN R. DALLAS/FATHER
ADDRESS OF EMERGENCY ADDRESSEE (Include Zip Code)

222 PRUNE STREET, FLINT MI 48504
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE

(543) 214-7909
4-36. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY (MTF) a. Source of data. Self-explanatory (your MTF). b. Enter the name and location of the reporting MTF.

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EXAMPLE: NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

USAH, FORT SPLENDID, TX
4-37. TYPE OF DISPOSITION (FIELD 21, COLUMNS 73 THROUGH 74) a. Source of data. The AAD office. (Item 25, ITRCS). b. Enter the type of disposition of the patient (e.g., Duty, Transfer, Died, Discharged Home). c. Enter the appropriate data code from table 4-16. d. Use the disposition code "50" (CRO-Other) for stillbirths delivered outside your MTF and subsequently brought to the MTF for disposition of remains and for selected conditions of medical, legal, or other significance for which inpatient treatment is not required. EXAMPLE: 21. TYPE OF DISPOSITION 73 74

DIED

3
DESCRIPTION

Ø
DATA CODES

Active Duty Patients and Separations Returned to duty To Duty from TDRL (includes CRO) To PDRL from TDRL (includes CRO) AWOL (dropped from rolls) Separation/Retired--PDRL (includes CRO) Separation/Retired--TDRL (includes CRO)

Ø1 Ø2 Ø3 Ø4 1Ø 11

Table 4-16. Disposition type codes (continued).

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DESCRIPTION Active Duty Patients and Separations

DATA CODES

Separation W/Severance pay (includes CRO) Separation WO/Severance pay (includes CRO) Nondisability separation for drug/alcohol abuse at or after transfer or referral to NON-U.S. Armed Service MTF Separation for failure to meet medical procurement standards (includes CRO) Transferred--Army MTF Transferred--Navy MTF Transferred--Air Force MTF Discharged to other Federal facility (includes VA, Indian Health Service (IHS), excludes Army MTF, Navy MTF or Air Force MTF) Died during inpatient stay CRO--Dead on Arrival (DOA) CRO--ER Death CRO--Other CRO--Killed in action (KIA) Non-AD Patients Discharged Home Left against medical advice (AMA) Transferred--Army MTF Transferred--Navy MTF Transferred--Air Force MTF Discharged to other Federal facility (includes VA, IHS; Excludes Army MTF, Navy MTF, Air Force MTF) Discharged to civilian hospital, nursing home, convalescent Center Died during inpatient stay CRO--Dead on Arrival (DOA) CRO--ER Death CRO--Other

12 13 14 15 21 22 23 24

3Ø 41 42 5Ø 51

Ø5 Ø6 21 22 23 54 25 3Ø 41 42 5Ø

Table 4-16. Disposition type codes (concluded).

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4-38. MTF TRANSFERRED TO (FIELD 22, COLUMNS 75 THROUGH 80) a. Source of data. Self-explanatory. (Item 31, ITRCS). b. Enter the code for the MTF to which the patient is being moved. Locate a first position code from table 4-17, followed by the MTF code from table 4-1. A complete list of MTF codes can be found in the Individual Patient Data System (IPDS) User's Manual. c. If the transfer is to other than a U.S. military MTF, construct a three-position code. Locate a first position code from table 4-17. The second and third positions will either be a two-numeric state code from table 4-2, or a two-alpha character country code, or local civilian facilities may be assigned a number by your facility for catchment area management. The entire code should be no more than six characters and leftjustified. If positions 4, 5, and 6 are not coded for use at the local level, leave blank. d. In the following examples, the first patient was transferred to a civilian MTF in the state of Massachusetts; the second patient was transferred to Fitzsimons AMC, Denver CO.

EXAMPLES: 22. MTF TRANSFERRED TO 75 76 77 78 79 80

C 2

5

22. MTF TRANSFERRED TO 75 76 77 78 79 80

A 1

2 Ø 1

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DESCRIPTION

DATA CODES

Military Medical Treatment Facility Army MTF Navy MTF Air Force MTF Non-U.S. Military Medical Treatment Facility Civilian MTF Veterans Administration MTF Public and Indian Health MTF Foreign Military MTF Other MTF Table 4-17. First position MTF codes.

A N F

C V P M B

4-39. DATE OF DISPOSITION (FIELD 23, COLUMNS 81 THROUGH 86) a. Source of data. Self-explanatory. b. Enter the date of the patient's disposition from your MTF. If you have administrative responsibility for a patient in a civilian MTF (i.e., absent sick), enter the date the patient was removed from the census of the civilian MTF. Enter the same date as the "Date of this Admission" for a CRO case. EXAMPLE: EXAMPLE: 23. DATE OF DISPOSITION (YYMMDD) 81 82 83 84 85 86

29 JAN 9X

9

X Ø 1 2 9

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4-40. CLINIC SERVICE - ADMITTING (FIELD 24, COLUMNS 87 THROUGH 9Ø) a. Source of data. Designated by care provider/ physician. (Item 23, ITRCS). b. The mission of the MTF will determine the clinic services established in your facility. Enter the code from table 4-18 for the initial clinic service to which the patient is assigned upon admission. c. Leave the field blank for absent sick patients whose entire period of hospitalization was spent in that status and for CRO cases. For patients in a cooperative care or supplemental care status, use the code of the clinic service referring the patient to the civilian facility. d. If one of the following programs is applicable, change the fourth digit from "A" to one of the following codes: (1) E - Exceptional Family Member Program (EFMP). (2) O - Catchment Area Management Programs. (3) P - Partnership Programs. (4) R - Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) Reform Initiatives. (5) S - CRI/Resource Sharing Programs. (6) U - Alternate Use/CHAMPUS Funds. NOTE: Do not use the codes above for CRO (XXXA) and Absent Sick (YYYA).

EXAMPLE: 24. CLINIC SVC - ADMITTING 87 88 89 90

GEN SURG

A B

A A

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DESCRIPTION Clinic Service Adolescent Pediatrics Allergy Bone Marrow Transplant Cardiology Cardiovascular/Thoracic Surgery Clinical Immunology Coronary Care Unit Dermatology Endocrinology Gastroenterology General Surgery Gynecology Hand Surgery Head and Neck Surgery Hematology Human Immunodeficiency Virus (HIV) III, Acquired Immune Deficiency Syndrome (AIDS) Referral Center Infectious Disease Institute of Surgical Research (Burn Center, Brooke Army Medical Center (BAMC) only) Internal Medicine Medical Intensive Care Unit Neonatal Intensive Care Unit

ABBREVIATION

DATA CODE

Adol Ped Algy Marr Trans Cardio Cv/Thor Surg Cl Immu CCU Derm Endocrn Gastro Gen Surg GYN Hand Surg Hd/Nk Surg Hem

ADDA AASA AAQA AABA ABBA AAOA AACA AADA AECA ABPA ABAA ACAA AECA ABPA AAGA

HIV Inf Dis

AAPA AARA

ISR Int Med MICU NICU

ABMA AAAA AAHA ADCA

Table 4-18. Medical Expense and Performance Reporting System (MEPRS) clinic service codes (continued).

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DESCRIPTION Nephrology Neurology Neurosurgery Nursery Obstetrics Oncology Ophthalmology Oral Surgery Organ Transplant, Walter Reed Army Medical Center (WRAMC) Orthopedics Otorhinolaryngology Pediatrics Pediatric Surgery Peripheral Vascular Surgery Physical Medicine Plastic Surgery Podiatry Proctology Psychiatry Pulmonary/Upper Respiratory Disease Rheumatology Substance Abuse Rehabilitation Surgical Intensive Care Unit Trauma Center Urology

ABBREVIATION Nephro Neuro Neuro Surg Nsy OB Oncol Ophth Oral Surg Org Trans Ortho ENT Ped Ped Surg PV Surg Phys Med Plas Surg Pod Procto Psy Pulm Dis Rheum SA Rehab SICU Trau Ctr Urol

DATA CODE AAIA AAJA ABDA ADBA ACBA AAKA ABEA ABFA ABLA AEAA ABGA ADAA ABHA ABNA AANA ABIA AEBA ABJA AFAA AALA AAMA AFBA ABCA ABOA ABKA

Table 4-18. Medical Expense and Performance Reporting System (MEPRS) clinic service codes (continued).

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DESCRIPTION Family Practice (FP) FP Gynecology FP Medicine FP Nursery FP Obstetrics FP Orthopedics FP Pediatrics FP Psychiatry FP Surgery Carded for Record Only Absent Sick

ABBREVIATION

DATA CODE

FP GYN FP Med FP Nsy FP OB FP Ortho FP Ped FP Psy FP Surg CRO Abs Sk

AGEA AGAA AGHA AGCA AGGA AGDA AGFA AGBA XXXA YYYA

Table 4-18. Medical Expense and Performance Reporting System (MEPRS) clinic service codes (concluded).

4-41. MTF TRANSFERRED FROM (FIELD 25, COLUMNS 91 THROUGH 96) a. Source of data. Self-explanatory. (Item 31, ITRCS). b. Enter the code for the MTF from which the patient was received. Locate a first position code from table 4-17, followed by the MTF code from table 4-1. c. If the transfer is from other than a U.S. military MTF, construct a three-position code. Use the same coding procedure as in MTF transferred to (field 22). d. In the fo llowing example, the patient was transferred from a foreign military MTF in the United Kingdom. EXAMPLE: 25. MTF TRANSFERRED FROM 91 92 93 94 95 96

M U K

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4-42. DATE OF THIS ADMISSION (FIELD 26, COLUMNS 97 THROUGH 102) a. Source of data. AAD office. (Item 28, ITRCS). b. Enter the date of the patient's actual admission to your MTF. c. For AD Army personnel with entire hospitalization in an absent sick status (source of admission data code 3), leave this field blank. For AD Army personnel who are change-of-status in to your MTF (source of admission data code 4), enter the date of the change-of-status. d. For CRO cases, enter the date of notification or preparation of record. Enter the actual date of treatment, if it is different from notification/preparation in item 31, ITRCS. e. For transfer admissions, enter the date the patient arrived at your MTF. EXAMPLE: 26. DATE OF THIS ADMISSION (YYMMDD) 97 98 99 100 101 102

8 JAN 9X

9

X

Ø

1

Ø

8

4-43. LOCATION OF OCCURRENCE (FIELD 27, COLUMNS 103 THROUGH 104) a. Source of data. Admission interview. b. Enter state codes from table 4-2 or country location codes (located in the IPDS User's Manual) to indicate geographical location for all patients treated during deployment. The receiving MTF for a transfer case must record the original location of occurrence code. NOTE: The directive to use this field for "Battle Casualty Only" was rescinded in November 1990. This field may be used for all cases.

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EXAMPLE: 27. LOCATION OF OCCURRENCE 103 104 (Battle Casualty Only)

SAUDI ARABIA S A

4-44. MTF OF INITIAL ADMISSION (FIELD 28, COLUMNS 105 THROUGH 110) a. Source of data. Admissions office and Item 31, ITRCS. b. Leave this field blank for direct admissions to your MTF. c. For transfer admissions, enter the code for the first MTF to which the patient was admitted for the current episode of illness/ injury. Locate a first position code from table 4-17, followed by the MTF code from table 4-1. A complete list of MTF codes can be found in the Individual Patient Data (IPDS) User's Manual. d. If the initial admission was to other than a U.S. military MTF, construct a three-position code. Locate a first position code in table 4-17. The second and third positions will either be a two-numeric state code from table 4-2, or a two-alpha character country code, or local civilian facilities may be assigned a number by your facility for catchment area management. The entire code should be no more than six characters and left-justified. e. For Army hospitals not listed in this document or the IPDS user's manual, contact PASBA, Medical Summary Branch, DSN 471-5579 for the codes. f. In the following examples, one patient was initially admitted to JTF-B Med El in Honduras; another was initially admitted to an Indian Health Service hospital in North Dakota.

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EXAMPLES: 28. MTF OF INITIAL ADMISSION 105 106 107 108 109 110

JTF HONDURAS

A

Ø

1

K

1

28. MTF OF INITIAL ADMISSION 105 106 107 108 109 110

IHS, NORTH DAKATO

P

3

8

4-45. DATE OF INITIAL ADMISSION (FIELD 29, COLUMNS 111 THROUGH 116) a. Source of data. Medical records accompanying the transfer patient or absent sick notification. b. Enter the date when first admitted for this continuous period of hospitalization for total absent sick cases, transfer patients, and those admitted from absent sick status. Leave blank for all other cases. EXAMPLE: 29. DATE OF INITIAL ADMISSION (YYMMDD) 111 112 113 114 115 116

19 FEB 9X

9

X

Ø

2

1

9

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4-46. FOR LOCAL USE. The reporting MTF will determine entries made in this area. EXAMPLE: FOR LOCAL USE

FX HUMERUS, OPEN OPEN REDUCTION WITH INTERNAL FIXATION DEVICE

TRIPPED AND FELL ON RT ARM IN HOME AT 1400 ON DATE OFADMISSION

4-47. ADMITTING OFFICER a. Source of data. Self-explanatory. b. Enter the name of the physician or other care provider authorizing admission. If the A&C Form is used as the admission authorization, the admitting officer should sign in this area.

EXAMPLE: ADMITTING OFFICER (Signature, as required)

Ellis P. Brewster, COL, MC

4-48. SIGNATURE OF ADMITTING CLERK a. Source of data. Self-explanatory. b. The admitting clerk should sign in this area.

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EXAMPLE: SIGNATURE OF ADMITTING CLERK

IMA CLARK
NOTE: You will now begin coding page 2, DA Form 2985.

4-49. AGE AT DISPOSITION (FIELD 30, COLUMNS 117 THROUGH 119) a. Source of data. Calculated in AQCESS/CHCS. For nonautomated sites, AAD office. b. For live births and transferred live births with ØØD (age at admission) in field 7, age will be the actual number of days from birth to disposition. c. Nonautomated sites should add a year or more as appropriate if the patient has had a birthday(s) during this period of hospitalization. d. Enter the patient's age in completed days, months, or years at the time of this disposition. Select the appropriate code from table 4-5. If days, months, or years of age are less than 10, enter a zero in the first position (i.e., Ø8M). If the patient is 1 year old or older, enter the age in completed years except that the code "99Y" will be used for patients 99 years or older.

EXAMPLE: 30. AGE AT DISP 117 118 119

1

8

Y

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4-50. AUTOPSY (FIELD 31, COLUMN 120) a. Source of data. Patient's clinical record, items 25 and 31, ITRCS.

b. Enter "Y" for yes and "N" for no to indicate whether or not an autopsy was performed. An entry is required for all death cases including CRO. For other than death cases, leave this field blank . EXAMPLE: 31. AUTOPSY 120 Y/N

Y
4-51. UNDERLYING CAUSE OF DEATH/SEPARATION (FIELD 32, COLUMN 121) a. Source of data. Item 34, ITRCS. b. This code indicates which of the eight diagnostic fields identifies the cause of death in both inpatient deaths and CRO cases. Select the data code (1 through 8) from table 4-19. c. Separations from service for disability. (1) For injury cases, select the data code (1 through 8) from table 4-19 that identifies the field in which the underlying cause of disability for current injury is coded. A code for residual disability is required in field 33. (2) For disease cases, select the data code (1 through 8) from table 4-19 that identifies the field in which the principal disabling disease is coded. No residual disability code is required for disease cases. d. For separation from service for failure to meet medical procurement standards, select data code (1 through 8) from table 4-19 that identifies the field in which the principal cause of separation is coded. No residual disability code is required.

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EXAMPLE: 32. UNDERLYING CAUSE 121 OF DEATH/SEP

1
e. The underlying cause of death or principal cause of separation/retirement, or the principal cause for failure to meet medical fitness standards appears in the field indicated by the data code in the following table. DESCRIPTION Field 36 Field 37 Field 38 Field 39 Field 40 Field 41 Field 42 Field 43 DATA CODES 1 2 3 4 5 6 7 8 Table 4-19. Underlying cause of death/separation codes.

4-52. RESIDUAL DISABILITY (FIELD 33, COLUMNS 122 THROUGH 124) Leave this field blank. Residual disability collection has been discontinued. 4-53. DATA FILLER (FIELD 34, COLUMNS 125 THROUGH 133) Leave this field blank. This field is reserved for future use. 4-54. CAUSE OF INJURY (FIELD 35, COLUMNS 134 THROUGH 136) a. Source of data. Item 33, ITRCS. b. Enter a cause of injury code for any injury diagnosis (codes 8000 to 9999, 692.71, V71.3 to V71.6, and E9300 to E9499) appearing in diagnostic fields 36 to 43

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on the A&C Form. If more than one injury diagnosis is recorded in fields 36-43, enter a cause of injury code in field 35 for the first injury. c. External cause of injury STANAG code structure. The three digits of the code provides identification of specific causative agents with 12 broad categories, along with additional information on the place of occurrence for categories VIII through XII. The 12 broad categories are as follows: I ØØØ-Ø59 Accidents in air transport, as specifically defined; spacecraft accidents and escape system injuries. Accidents in land transport, as specifically defined. Accidents in water transport, as specifically defined. Athletics and sports. Reactions, complications, and misadventures in medical or surgical procedures; and late complications or late effects. Instrumentalities of war, when employed by the enemy in wartime. Accidents in connection with own instrumentalities of war when employed as such in wartime. Guns, explosives, and related agents except when used as instrumentalities of war in wartime. Machinery, tools, and selected agents. Poisons, fire, hot or corrosive substances. Specified environmental factors (natural or artificial environment). Falls and miscellaneous other or unspecified agents.

II III IV V

1ØØ-149 15Ø-199 2ØØ-249 25Ø-299

VI

3ØØ-479

VII

48Ø-499

VIII

5Ø-59*

Ix X Xi Xii

60*-60* 70*-79* 80*-89* 9Ø*-99*

*Third digit is place of occurrence code. d. Transport accidents. The first three categories of the causative agent codes include mishaps which are defined as transport accidents on land, in air, or in water.

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The mishap must have occurred during the use of these means of transport and that occurrence must have been a result of the hazards related to such use (i.e., a fall aboard ship would not be considered a hazard related to transport by ship). The use is considered to have begun when personnel board for the purpose of transport. e. Place of occurrence. Categories VIII to XII require the use of standard thirddigit "place of occurrence" codes (see table 4-20). In the following example, the patient was assaulted by an unknown person at the barracks. The first and second positions (97) are for the external cause of injury. The third-digit position (8) indicates the place of occurrence. EXAMPLE: 35. CAUSE OF INJURY 134 135 136

9

7

8
DATA CODE Ø 1 2 3 4 5 6 7 8 9

PLACE OF OCCURRENCE OF INJURY Onboard aircraft, spacecraft, in the air or in space Onboard ship, other water transport, or in water/sea, river, lake, etc. On land and at an airfield On land and at a dock On land and at an industrial plant (e.g., ordnance factory, supply warehouse, repair shop) On land and on firing range, or drill field On land and on obstacle course On land and in kitchen (other than home), mess hall, or bakery On land and in the home, quarters, or barracks On land, other, or unspecified

Table 4-20. Place of occurrence of injury third-digit codes.

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4-55. DIAGNOSTIC CODING (FIELDS 36 TO 43, COLUMNS 137 THROUGH 200) a. Source of data. Item 34, ITRCS. b. Use the ICD-9-CM, Volumes 1 and 2, to code the diagnosis(es). Coding rules and principles are outlined in the Triservice Disease and Procedure Coding Guidelines, dated 1 January 1991. c. There are eight diagnostic fields. If there are fewer than eight diagnoses recorded on the ITRCS, leave unused fields blank. If there are more than eight diagnoses recorded on the ITRCS, use the following priorities to select only eight: (1) Select the principal diagnosis. The condition established by medical examinations and tests to be the primary reason for the patient's admission is the principal diagnosis and will be coded in field 36. When there are two or more diagnoses of equal importance present on admission, and when the medical record documentation does not indicate otherwise, the principal diagnosis is the one for which a definitive surgical or nonsurgical procedure was performed. If no definitive procedure was performed, any one of the diagnoses may be principal. (2) Select and record complications and/or co-morbidities. (3) Record diagnosis(es) relating to therapeutic procedures. (4) Record the underlying cause of death or cause of disability retirement/separation. (5) Select etiology codes prior to manifestation codes. (6) Select the remaining diagnoses which contributed most to prolonged hospitalization after recording diagnoses based on the above priorities. d. Use the first three/four/five columns in the diagnostic fields for ICD-9-CM codes. Do not zero-fill to the fourth column for three-digit codes. Leave the fifth column blank for four-digit codes. e. Leave the sixth column blank. This column is reserved for future use. f. Use the seventh column for DOD diagnostic code extenders. The codes that require an extender are listed in Appendix A, Triservice Disease and Procedure Coding Guidelines, dated 1 January 1991. (See Coding Principles, Appendix A of this subcourse.)

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g. Enter a code from table 4-21 in the eighth column to indicate where the diagnostic condition was treated or managed.

EXAMPLES: 36. FIRST DIAGNOSIS (Principal Diagnosis) 137 138 139 140 141 142 143 144

8

6

5

Ø

Ø

Ø

37. SECOND DIAGNOSIS 145 146 147 148 149 15Ø 151 152

8
PLACE OF TREATMENT

2

1

1

1
DATA CODE

Ø

Condition treated at or managed in reporting MTF CRO cases and admission source 3 (cases treated entirely in absent sick status) V27 diagnosis only--delivered at a civilian hospital Table 4-21. Place of treatment codes.

Ø Z C

NOTE: V27 diagnosis (outcome of delivery) may be coded with Ø, Z, or C. All other diagnoses may be coded with Ø or Z. 4-56. PROCEDURE CODING (FIELDS 44 TO 51, COLUMNS 201 THROUGH 264) a. Source of data. Item 34, ITRCS. b. Use ICD-9-CM, Volumn 3, to code the procedures. Coding rules and principles are outlined in the Triservice Disease and Procedure Coding Guidelines, dated 1 January 1991.

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c. There are eight procedure fields. If there are less than eight procedures recorded on the ITRCS, leave the remaining fields blank. If there are more than eight procedures recorded on the ITRCS, select only eight, using the following priorities: (1) Record the principal procedure first, in field 44. The principal procedure is the one performed for therapeutic rather than for diagnostic or exploratory purposes or to treat a complication. (2) Record procedures performed for underlying causes of death or disability retirement/separation. (3) Record the more significant procedures remaining that are related to conditions causing prolonged hospitalization or those which have special interest to the staff. d. Each procedure field has eight columns. Use the first three/four columns of each procedure field for the ICD-9-CM procedure code. For three-digit codes, do not zero-fill to the fourth column. e. Leave the fifth column blank. This column is reserved for future use. f. Use the sixth position to indicate where the procedure was performed. Enter a code from table 4-22. g. Enter a code, Ø1 to 99, in the seventh and eighth columns to indicate the number of times a procedure was performed at the reporting MTF during the current period of hospitalization. EXAMPLE: 44. FIRST PROCEDURE (Principal Diagnosis) 201 202 203 204 205 206 207 208

4

1

5

D

Ø

1

45. SECOND PROCEDURE 209 210 211 212 213 214 215 216

7

9

3

6

D

Ø

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PLACE OF PERFORMANCE OF PROCEDURE This MTF, not CRO patient This MTF, CRO patient Same Day Surgery Program Nonhospital facility Civilian hospital Another federal facility during current hospitalization this MTF (not for procedures performed prior to transfer admission)

DATA CODE D R X T C J

Table 4-22. Surgical procedures place of performance codes.

4-57. NUMBER OF DIAGNOSTIC FIELDS CONTAINING CODES (FIELD 52, COLUMNS 265 THROUGH 266) a. Source of data. Item 34, ITRCS. b. Total is system generated by AQCESS/CHCS. For nonautomated sites, enter the total number of fields used to code the patient's diagnosis(es). c. This field is right-justified and zero-filled to the left. EXAMPLE: 52. NUMBER OF DIAGNOSTIC FIELDS 265 266 CONTAINING CODES

Ø

3

4-58. NUMBER OF PROCEDURAL FIELDS CONTAINING CODES (FIELD 54, COLUMNS 269 THROUGH 271) a. Source of data. Item 34, ITRCS. b. Total is system-generated by AQCESS/CHCS. For nonautomated sites, enter the total number of fields used to code any procedures the patient has undergone. c. This field is right-justified and zero-filled to the left.

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EXAMPLE: 53. NUMBER OF PROCEDURAL FIELDS 267 268 CONTAINING CODES

Ø

3

4-59. PRIMARY PROVIDER SPECIALTY CODE (FIELD 54, COLUMNS 269 THROUGH 271) a. Source of data. The AAD office. b. This is an optional field for U.S. Army facilities. The code is system generated by AQCESS/CHCS. Nonautomated sites should select a code from Appendix F, Individual Patient Data System (IPDS) User's Manual if your MTF chooses to code this field. In the following example, the specialization of the primary provider is general surgeon. EXAMPLE: 54. PRIMARY PROVIDER 269 270 271 SPECIALTY CODE

1

Ø

Ø

4-60. BLOOD USAGE (FIELD 55, COLUMN 272) a. Source of data. System-generated by AQCESS/CHCS if the blood utilization screen is completed. If the screen is not completed and for nonautomated sites, Item 32, ITRCS. b. Enter "Y" for yes, blood or blood components was transfused. If no blood or blood components was transfused, enter "N" for no. In the following example the patient received 4 units of blood.

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EXAMPLE: 55. BLOOD USAGE 272 Y/N

Y
NOTE: You will now begin coding page 3, DA Form 2985. Nonautomated sites should enter the code from page one for the Reporting MTF and the patient's register number. 4-61. TOTAL SICK DAYS ALL FACILITIES (FIELD 56, COLUMNS 273 THROUGH 277) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, this is the number of days between the date of initial admission and the date of disposition from your facility. b. Patient days entered in this field represent total days to date at all facilities. However, sick days in a civilian facility are counted for AD personnel only. (1) Direct, Absent Sick. Enter the number of days between date of initial admission and the date of disposition. (Using a Julian calendar, subtract the day of disposition from the day of initial admission.) This number should equal the total number of sick days this MTF (field 67) plus the number of sick days at all other facilities (fields 58-59). (2) Total Absent Sick. Enter the number of days between date of initial admission and date of disposition. (Using a Julian calendar, subtract the day of disposition from the day of initial admission). There is no "date of this admission" on this record. This number should be the same as the number in field 67. (3) Carded for Record Only (CRO). Enter "Ø" days in this field as well as in field 67 and all other field requiring the number of sick/bed days for CRO cases. (4) Direct Admission. Enter the number of days between date of this admission and date of disposition. (Using a Julian calendar, subtract the day of disposition from the day of this admission.) For a direct admission and final

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disposition on the same date, enter ØØØØ1. For a direct admission with "transfer" disposition on the same date, enter ØØØØØ. These totals should be the same as the entry in field 67. (5) Admission by Transfer. Enter the number of days between date of initial admission and date of disposition. (Using a Julian calendar, subtract the day of disposition from the day of initial admission.) This total should be the sum of the sick days at your MTF in field 67 and plus sick days at all other facilities. For a case transferred in and dispositioned by transfer on the same date, enter the total for all other facilities. Your MTF gets ØØØØØ sick days. For a transfer case with final disposition on the same date, your facility gets ØØØØ1 sick day. Enter the sum of one sick day at your facility plus the total number of days at all other facilities. EXAMPLE: 56. TOTAL SICK DAYS (ALL FACILITIES) 273 274 275 276 277

Ø

Ø

Ø

2

1

4-62. BED DAYS THIS MTF (FIELD 57, COLUMNS 278 THROUGH 281) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. Items 35F or 36F, ITRCS for nonautomated sites. b. For nonautomated sites: (1) Enter the total days the patient occupied a bed in your facility. A patient on pass for periods not exceeding 72 hours will be considered as occupying a bed during that period. (2) Days that a patient was in an absent status will not be counted as bed days this MTF. (3) Days that a patient spent in the labor or delivery room and neonatal intensive care nursery will be counted as bed days in this MTF. Days spent by a newborn in the newborn nursery will be counted as bassinet days. (4) A bed day is also counted when a patient is admitted and dispositioned (final disposition) on the same day.

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(5) Bed days this MTF is the difference between the number of total sick days this MTF (field 67) minus the total of any days in fields 58 to 66. EXAMPLE: 57. BED DAYS THIS MTF 278 279 280 281

Ø

Ø

2

1

4-63. BED DAYS OTHER FEDERAL MTFS (FIELD 58, COLUMNS 282 THROUGH 285) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. Items 21 and 31, ITRCS for nonautomated sites. b. For nonautomated sites, enter the total number of days spent in other Federal MTFs during this period of hospitalization. Patients must be in a status-out to another Federal facility (source of admission 6, 7, or 8). In the following example, the patient was hospitalized for 3 days in another Federal MTF before transfer to your MTF. EXAMPLE: 58. BED DAYS OTHER FED MTFS 282 283 284 285

Ø

Ø

Ø

3

4-64. BED DAYS CIVILIAN HOSPITALS (FIELD 59, COLUMNS 286 THROUGH 289) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, Items 21 and 31, ITRCS. b. The source of admission (field 20) for the patient must be absent sick. c. For a patient initially absent sick in a civilian facility and subsequently moved to your MTF, the absent sick civilian bed days will be the difference between the date of initial admission and the date of this admission. Using a Julian calendar, subtract day of this admission from day of initial admission.

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d. Enter the total number of absent sick civilian bed days during the period for which your MTF had administrative control of the AD Army patient. In the following example, the patient was initially absent sick in a civilian MTF on 7 March 199X (Julian day 066) and admitted to your MTF on 9 March 199X (Julian day 068). EXAMPLE: 59. BED DAYS - CIV HOSPITALS 286 287 288 289

Ø

Ø

Ø

2

4-65. BASSINET DAYS (NEONATAL) (FIELD 60, COLUMNS 290 THROUGH 293) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, the source of admission must be a live birth at your facility. b. For nonautomated sites, enter the number of days that a live-born resides in a newborn nursery. Do not include those "newborns" born outside of your facility and subsequently admitted. Do not include days spent in the neonatal intensive care nursery. EXAMPLE: 60. BASSINET DAYS - (NEONATAL) 290 291 292 293

Ø

Ø

Ø

3

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4-64

4-66. QUARTERS DAYS (FIELD 61, COLUMNS 294 THROUGH 297). This field is not used. EXAMPLE: 61. QUARTERS DAYS 294 295 296 297

4-67. MEDICAL HOLDING DAYS (FIELD 62, COLUMNS 298 THROUGH 301) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, patients must be in a status-out to medical hold in AAD to accrue days in this category. b. For nonautomated sites, enter the total number of days spent by AD service members assigned to the medical holding unit/ward. EXAMPLE: 62. MEDICAL HOLDING DAYS 298 299 300 301

Ø

Ø

1

6

4-68. COOPERATIVE CARE DAYS (FIELD 63, COLUMNS 302 THROUGH 305) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. Patients must be in a status-out to cooperative care in AAD in order to accrue days in this category. For nonautomated sites, Item 31, ITRCS.

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b. Enter the total days spent in a cooperative care status by a Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) eligible patient. EXAMPLE: 63. COOPERATIVE CARE DAYS 302 303 304 305

Ø

Ø

Ø

2

4-69. CONVALESCENT LEAVE DAYS (FIELD 64, COLUMNS 306 THROUGH 309) a. Source o f data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, Item 31, ITRCS. b. This field is for AD patients only. c. For nonautomated sites, enter the convalescent leave days actually taken before the patient was dispositioned from your MTF. EXAMPLE: 64. CONVALESCENT LEAVE DAYS 306 307 308 309

Ø

Ø

2

8

4-70. SUPPLEMENTAL CARE DAYS (FIELD 65, COLUMNS 310 THROUGH 313) a. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. Patients must be in a status-out to supplemental care in AAD to accrue days in this category. For nonautomated sites, Item 31, ITRCS.

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b. For nonautomated sites, enter the total days spent in supplement care status. EXAMPLE: 65. SUPPLEMENTAL CARE DAYS 310 311 312 313

Ø

Ø

Ø

5

4-71. OTHER DAYS (FIELD 66, COLUMNS 314 THROUGH 317) a. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, an itemized breakdown of days in this category will be entered in Item 31, ITRCS. b. For nonautomated sites, enter the total number of days spent in a status-out in AAD to AWOL (away without leave), to PCS (permanent change of station) home, to PCS VA, to subsisting out, to TDY, or to other authorized absence (i.e., leave). EXAMPLE: 66. OTHER DAYS 314 315 316 317

Ø

Ø

2

2

4-72. TOTAL SICK DAYS - THIS MTF (FIELD 67, COLUMNS 318 THROUGH 322) a. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, this is the sum of fields 57 to 66. b. For nonautomated sites, enter the total sick days the patient spent at your MTF. (1) For direct admissions, subtract "Date of This Admission" (field 26) from "Date of Disposition" (field 23) except for final disposition on the same day as admission.

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(2) For total absent sick cases, subtract "Date of Initial Admission: (field 29) from "Date of Disposition" (field 23) except for final disposition on the same day as date of initial admission. Although total absent sick cases will have zero bed days in your MTF, these patients have been carried administratively on your hospital rolls during this time. (3) For cases when initial admission and final disposition occur on the same day, the MTF making final disposition will enter "ØØØØ1." This is considered 1 sick day. (4) For CRO cases and admissions with transfer dispositions on the same day, enter "ØØØØØ." c. One method of calculating these days is to convert the dates to Julian calendar days and subtract as in the following example. Date of Disposition is 5 May 9X Date of This Admission is 15 Apr 9X Total Sick Days - This MTF Julian date is 125 Julian date is 105 (125 minus 105) 20

d. When a hospitalization begins in one calendar year and ends the following year, first convert to Julian dates, then subtract the date of this admission from the number of days in the year (remember, a leap year will have 366 days), then add the sick days during admission year to the Julian date of disposition. Number of days in the year Date of This Admission is 23 Dec 93 Sick days during admission year Date of Disposition is 13 Jan 94 Total Sick Days - This MTF 365 Julian date is 357 (365 minus 357) 08 Julian date is 013 (8 plus 13) 21

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EXAMPLE: 67. TOTAL SICK DAYS - THIS MTF 318 319 320 321 322

Ø

Ø

Ø

2

1

4-73. BED DAYS - INTENSIVE CARE UNIT (FIELD 68, COLUMNS 323 THROUGH 326) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. Bed days spent in ICU are all or part of bed days this MTF but are reported separately. Accuracy in reporting bed days in the ICU is very important due to the high cost of operating these units. c. For nonautomated sites, enter the total number of days that the patient was assigned to the intensive care unit (ICU) if your MTF is authorized intensive care clinical services. EXAMPLE: 68. BED DAYS - ICU 323 324 325 326

Ø

Ø

Ø

8

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Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Jan 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 018 019 020 021 022 023 024 025 026 027 028 029 030 031

Feb 032 033 034 035 036 037 038 039 040 041 042 043 044 045 046 047 048 049 050 051 052 053 054 055 056 057 058 059

Mar 060 061 062 063 064 065 066 067 068 069 070 071 072 073 074 075 076 077 078 079 080 081 082 083 084 085 086 087 088 089 090

Apr 091 092 093 094 095 096 097 098 099 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120

May 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151

Jun 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181

Jul 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212

Aug 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243

Sep 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273

Oct 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304

Nov 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334

Dec 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365

Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

FOR LEAP YEAR USE REVERSE SIDE Figure 4-3. Julian Date Calendar (Perpetual).

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4-74. BED DAYS - ADMITTING CLINIC SERVICE (FIELD 69, COLUMNS 327 THROUGH 330) a. Source of data. This field is system-generated by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. For nonautomated sites, enter the total number of days that the patient is assigned to the admitting clinic service during the entire period of hospitalization. For example, if a patient is admitted to General Surgery for 3 days, is moved to Cardiology for 2 days, returns to General Surgery for 6 days, is subsequently moved to Internal Medicine for 2 days, and returns to General Surgery for 12 days before final disposition, the total bed days accrued in the admitting clinic service (General Surgery) is 21. EXAMPLE: 69. BED DAYS - ADMITTING 327 328 329 33Ø CLINIC SERVICE

Ø

Ø

2

1

4-75. CLINIC SERVICE - SECOND (FIELD 70, COLUMNS 331 THROUGH 334) a. Source of data. This field is system-generated by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. For nonautomated sites, enter the MEPRS clinic code (see table 4-18) for the second clinic service to which the patient was assigned during this period of hospitalization. In the following example, Cardiology is the second clinic service to which the patient is assigned. EXAMPLE: 70. CLINIC SERVICE (SECOND) 331 332 333 334

A

A

B

A

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4-76. BED DAYS SECOND CLINIC SERVICE (FIELD 71, COLUMNS 335 THROUGH 338) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. For nonautomated sites, enter the total number of days that the patient was assigned to the second separate/different MEPRS clinical service. In the following example, the patient was assigned to the second clinic service (Cardiology) for 2 days. EXAMPLE: 71. BED DAYS SECOND CLINIC SERVICE 335 336 337 338

Ø

Ø

Ø

2

4-77. CLINIC SERVICE THIRD (FIELD 72, COLUMNS 339 THROUGH 342) a. Source of data. This field is system-generated by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. For nonautomated sites, enter the MEPRS clinic code (see table 4-18) for the third separate/different clinical service to which the patient was assigned during this period of hospitalization. In the following example, Internal Medicine is the third clinical service to which the patient is assigned. EXAMPLE: 70. CLINIC SERVICE (THIRD) 339 340 341 342

A

A

A

A

4-78. BED DAYS THIRD CLINIC SERVICE (FIELD 73, COLUMNS 343 THROUGH 346) a. Source of data. This field is automatically computed by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office.

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b. For nonautomated sites, enter the total number of days that the patient was assigned to the third separate/different MEPRS clinic service. In the following example, the patient was assigned to the third clinic service (Internal Medicine) for 2 bed days. EXAMPLE: 73. BED DAYS THIRD CLINIC SERVICE 343 344 345 346

Ø

Ø

Ø

2

4-79. CLINIC SERVICE DISPOSITION (FIELD 74, COLUMNS 347 THROUGH 350) a. Source of data . This field is system-generated by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office. b. For nonautomated sites, enter the MEPRS clinical service code (see table 418) for the service from which the patient was dispositioned. Report CRO cases as MEPRS code XXXA and total absent sick cases as YYYA. c. With few exceptions, the clinic service from which the patient is dispositioned will be the admitting (field 24), the second (field 70), or third (field 72) clinic service to which the patient was assigned. In the following example, the patient is dispositioned from General Surgery, the admitting clinic service. EXAMPLE: 70. CLINIC SERVICE DISPOSITION 347 348 349 350

A

B

A

A

4-80. BED DAYS DISPOSITION CLINIC SERVICE (FIELD 75, COLUMNS 351 THROUGH 354) a. Source of data. This field is system-generated by AQCESS/CHCS based on transactions processed in AAD. For nonautomated sites, AAD office.

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b. For nonautomated sites, enter the total number of days that the patient spent in the dispositioning clinic service for the entire period of this hospitalization. c. In the following example, the patient accrued 21 total bed days in the dispositioning clinic service. EXAMPLE: 75. BED DAYS DISPOSITION 351 352 353 354 CLINIC SERVICE

Ø

Ø

2

1

4-81. CONVALESCENT LEAVE RECOMMENDED (FIELD 76, COLUMNS 355 THROUGH 357) a. Source of data. Discharge summary, narrative summary or nurse's notes. b. These are convalescent leave days recommended by the discharging physician to an AD service member's unit commander. c. This field will be completed by clinical records personnel. In the following example, 10 days of convalescent leave was recommended by the physician. EXAMPLE: 76. CONVALESCENT LEAVE RECOM355 356 357 MENDED

Ø

1

Ø

4-82. PATIENT ACUITY DAYS (FIELDS 77 TO 82, COLUMNS 358 THROUGH 381) These fields are reserved for future use. Upon implementation of a patient acuity system, the user's manual will be updated. Leave these fields blank.

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4-83. DO NOT USE THIS SPACE (FIELD 83, COLUMNS 382 THROUGH 387) a. The AQCESS/CHCS systems will place an "F" in the first position of this field for those records forced through edits in the clinical records module. b. For nonautomated sites, leave this field blank. 4-84. TYPE RECORD (FIELD 84, COLUMNS 388 THROUGH 393) a. This field is system-generated or updated at transmittal time by AQCESS/CHCS. For nonautomated sites, the following codes will be used to identify the disposition status of records. b. The first column indicates the disposition of the record. (1) Code "D" is for records of dispositioned patients where the clinical records supervisor has approved the record for transmittal to PASBA. Currently, only D records will be sent by TOE hospitals and other nonautomated sites. (2) Code "E" is for incomplete records of dispositioned patients. (3) Code "F" is for records of patients currently on hospital rolls the date of the monthly IPDS records transmittal. (4) Code "C" is for record cancellation. The C record will be produced if a D, E, or F record was previously transmitted to PASBA and then had to be cancelled. Cancelled records will not be used for reporting purposes by PASBA. (5) A record coded D or E in the first column of the type record field will replace any record at PASBA coded F, if the MTF code and the patient register number are the same as on the record being replaced. A record coded D will replace a record coded E if the MTF code and the patient register number are the same as on the record being replaced. c. The second column of the type record field indicates the number of times the record has been transmitted (change version). Acceptable codes are Ø-9. If more than nine changes to a record are transmitted, use A-M. Change version numbers will begin with zero each time a different record disposition status is reported (i.e., D, E, F, C). d. The third throug h sixth columns of this field indicate the year and month of transmittal. The format is YYMM. The date indicator must be updated with each subsequent transmittal of any record.

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e. In the following example, the record of a dispositioned patient, which has been approved by the clinical records supervisor, was transmitted for the first time in January 199X.

EXAMPLE: 84. TYPE RECORD 388 389 390 391 392 393

D

Ø

9

X

Ø

1

Section III. CODING OF THE A&C FORM FROM THE U.S. FIELD MEDICAL CARD (FMC) 4-85. GENERAL. DD Form 1380, U.S. Field Medical Card (FMC) (see figure 4-4) is used to record data similar to that recorded on the ITRCS. The FMC is used by aid stations, clearing stations, and nonfixed troop or health clinics treating patients while overseas, on maneuvers, or attached to commands moving between stations. It is also used to record outpatient visits when the health records are not readily available during a mass casualty situation. Instructions for the preparation of the FMC are outlined in Chapter 9, AR 40-66 dated 20 July 1992 and in Subcourse MD0751. 4-86. CODING INSTRUCTIONS a. Information from the FMC is encoded on DA Form 2985 (A&C Form) only when the FMC reflects a final disposition or when it represents a CRO. Information on the FMC of patients transferred to a hospital is incorporated on the A&C Form prepared at the gaining hospital. b. Instructions for completing the fields on DA Form 2985 (A&C Form) which should be coded from the FMC are provided in this lesson. Only those fields on the A&C Form for which instructions are provided will be coded from the FMC. Instructions are also provided for field 5 (sex) which is not recorded on the FMC but which will be coded on the A&C Form. Unused fields will be left blank. 4-87. MTF CODE (FIELD 1, COLUMNS 2 THROUGH 5) NOTE: In the following instructions, items cited as "Source of Data" correspond to the numbered items on the FMC. MD0753 4-76

a. Source of data. The AAD office. See also paragraph 4-7 of this lesson. b. Enter the code for the gaining MTF from table 4-1. Codes listed in table 4-1, as well as TOE Hospital codes, may be found in the Individual Patient Data System (IPDS) User's Manual. 4-88. REGISTER NUMBER (FIELD 3, COLUMNS 9 THROUGH 15) a. Source of data. The AAD office. See also paragraph 4-9 of this lesson. b. Enter the next available register number from the register number log book for each admission. Register numbers begin with number one for the first patient admitted to the reporting MTF and continues consecutively until close of the facility.

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Figure 4-4. DD Form 1380 (U.S. Field Medical Card).

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4-89. PAY GRADE (FIELD 4, COLUMNS 16 THROUGH 17) a. Source of data. Item 3, FMC. See also paragraph 4-11. b. Enter the appropriate data code from table 4-3. Record the patient's pay grade as of the date the casualty occurred.

4-90. SEX (FIELD 5, COLUMN 18) a. Source of data. Remarks section of the FMC. See also paragraph 4-12. b. Enter the appropriate code (M for male, F for female) from table 4-4. 4-91. AGE AT ADMISSION (FIELD 7, COLUMNS 27 THROUGH 29) a. Source of data. Item 9, FMC. See also paragraph 4-14. b. Enter the appropriate data code from table 4-5. 4-92. RACE (FIELD 8, COLUMN 30) a. Source of data. Item 10, FMC. See paragraph 4-15. b. Enter the appropriate data code from table 4-6.

4-93. LENGTH OF SERVICE (FIELD 10, COLUMNS 32 THROUGH 34) a. Source of data. Item 8, FMC. See also paragraph 4-18. b. Enter the appropriate data code from table 4-9. 4-94. SOCIAL SECURITY NUMBER (SSN) (FIELD 12, COLUMNS 37 THROUGH 45) a. Source of data. Item 2, FMC. See also paragraph 4-21. b. Enter the complete SSN for U.S. active duty uniformed services personnel.

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4-95. BENEFICIARY CATEGORY (FIELD 15, COLUMNS 50 THROUGH 52) a. Source of data. Item 5, FMC and AAD office. b. Enter the appropriate data code from table 4-13. 4-96. UNIT LOCATION (STATE OR COUNTRY CODE) (FIELD 17, COLUMNS 62 THROUGH 63) a. Source of data. The AAD office. See also paragraph 4-29. b. Enter the state code from table 4-2 or country location code from the list in the Individual Patient Data System (IPDS) User's Manual. For units operating outside of their home station, this is the deployed location of operation. 4-97. TRAUMA (FIELD 19, COLUMN 71) a. Source of data. Items 16 and 19, FMC. See also paragraph 4-31. b. Enter the appropriate data code from table 4-14. A cause of injury code must also be entered in field 35. 4-98. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION (FIELD 20, COLUMN 72) a. Source of data. The source of admission will be direct to military hospital from other than the emergency room for all cases except CRO. The authority for admission is not applicable. See also paragraph 4-22. b. Enter the code "1" for all cases except CRO. Enter "C" for CRO cases. 4-99. TYPE OF DISPOSITION (FIELD 21, COLUMNS 73 THROUGH 74) a. Source of data. Item 27, FMC. See also paragraph 4-32. b. Enter appropriate code from table 4-15. 4-100. DATE OF DISPOSITION (FIELD 23, COLUMNS 81 THROUGH 86) a. Source of data. Item 28, FMC. See also paragraph 4-37. b. Enter the date of disposition using the format YYMMDD, where Y = year, M = month, and D = day.

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4-101. DATE OF THIS ADMISSION (FIELD 26, COLUMNS 97 THROUGH 102) a. Source of data. Item 13, FMC. See also paragraph 4-41. b. Enter the date of this admission using the format YYMMDD, where Y = year, M = month, and D = day.

4-102. TOTAL SICK DAYS THIS MTF (FIELD 67, COLUMNS 318 THROUGH 322) a. Source of data. Items 13 and 28, FMC. See also paragraph 4-69. b. Enter the number of days between the date the patient was admitted and the date of disposition. Enter "ØØØØØ" for CRO cases or for a patient who died or was transferred on the day of admission. Zero fill to the left. 4-103. CAUSE OF INJURY (FIELD 35, COLUMNS 134 THROUGH 136) a. Source of data. Items 14 and 19, FMC. See also paragraph 4-52. b. Enter the appropriate external cause of injury code from appendix B for patients suffering battle injuries or wounds, nonbattle accidents, violence, or poisonings (patients coded Ø through 9 in field 19). 4-104. UNDERLYING CAUSE OF DEATH (FIELD 32, COLUMN 121) a. Source of data. Item 14, FMC. See also paragraph 4-49. b. Enter the appropriate data code from table 4-19 to indicate which of the eight diagnostic fields identifies the cause of death. 4-105. DIAGNOSIS CODING (FIELDS 36 to 43, COLUMNS 137 THROUGH 200) a. Source of data. Item 14, FMC. b. Use the ICD-9-CM to code the diagnostic condition(s) for which the patient was treated. c. Use the first three/four/five columns of the diagnosis fields for the ICD-9-CM codes. Do not zero fill the fourth column for three-digit ICD-9-CM codes. Leave the fifth column blank for four-digit ICD-9-CM codes. d. Leave the sixth column blank.

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e. The seventh column is reserved for DOD diagnostic code extenders which are listed in Appendix A, Triservice Disease and Procedure Coding Guidelines, dated 1 January 1991. f. Enter a code from table 4-21 in the eighth column to indicate where the diagnostic condition was treated or managed. 4-106. PROCEDURES CODING (FIELDS 44 TO 51, COLUMNS 201 THROUGH 264) a. Source of data. Item 20, FMC. See also paragraph 4-54. b. Enter the three or four-digit code from ICD-9-CM, volume 3, in the first three or four columns of the procedures fields to indicate any surgical or other procedures that were performed on the patient. c. Do not zero fill to the fourth position for three-digit codes. d. Leave the fifth column blank. e. Enter a code from table 4-22 in the sixth column to indicate the place where the procedure was performed. f. Enter code Ø1-99 in the seventh and eighth columns to indicate the number of times a procedure was performed at the reporting MTF. 4-107. DISPOSITION OF THE FIELD MEDICAL CARD (FMC) a. If DD Form 1380, the Field Medical Card (FMC) is generated in a combat zone but the patient is not admitted to a hospital, the FMC will be sent to the medical command and control headquarters or the command surgeon for statistical coding. After coding, the FMC will be disposed of in accordance with (IAW) AR 40-66 and AR 25-400-2. b. When the patient is transferred to a hospital, the FMC will be used to prepare the inpatient treatment record (ITR). The FMC will then become part of the ITR. c. When the FMC is used to record outpatient treatment in peacetime operations or during training exercises, the original DD Form 1380 will be forwarded to the custodian of the patient's Health Record or Outpatient Treatment Record for inclusion in that record. d. All carbon copies of DD Form 1380 will be disposed of IAW AR 25-400-2.

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Section IV. TRANSMITTAL PROCEDURES AND DATA ACCESS

4-108. GENERAL a. The Automated Quality of Care Evaluation Support System (AQCESS) or Composite Health Care System (CHCS) Individual Patient Data System (IPDS) record transmittals will be submitted twice each month. Records must be submitted on the scheduled transmittal dates and should not be delayed to await late records. Late records should be submitted in the next scheduled transmittal. (1) Each month on or about the 4th working day, create a monthly transmittal tape. (2) Create an interim transmittal tape on or about the 15th working day of each month. b. Complete the IPDS records listed as missing on the monthly IPDS Records Report (RUC 299, Part C), and include these records in the next scheduled transmittal. c. Forward the magnetic tape/cassette by First-Class Mail or Priority Mail to Commander, U.S. Army Medical Department Center and School, Directorate of Patient Administration Systems and Biostatistics Activities, (HSHI-QPS), Fort Sam Houston, TX 78234-6100. d. Label each transmittal tape/cassette on the outside as follows: REPORTING MTF CODE: DATE CREATED: TYPE OF TRANSMITTAL: (End of Month or Interim) TOTAL RECORD COUNT: e. Enclose a copy of the corresponding Records Transmittal Roster to enhance accountability for every tape/cassette processed. f. Nonautomated sites requiring data reduction services by the U. S. Army Patient Administration Systems and Biostatistical Activity (PASBA) must use DA Form 2985, the three-page Admission and Coding Information Form (A&C Form) to record all patient data for processing into the data base. (1) Send a fully completed A&C Form plus DA Form 3647, the Inpatient Treatment Record Cover Sheet (ITRCS) to PASBA. (2) When it is not feasible to code diagnoses and procedures at that time, the A&C Form should be completely coded except for the diagnoses and procedures.

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g. For assistance, contact the Data Input Section, Patient Administration Systems Division, DSN 471-5414/6797. 4-109. PASBA2 a. PASBA2 is a program written to provide the medical treatment facilities quick, easy access to the data it submitted to the Directorate of Patient Administration Systems and Biostatistics Activities (PASBA), through the Individual Patient Data System (IPDS). The availability of this data enables clinicians and managers to make decisions about their patients and their facility in an expeditious manner. b. PASBA2 User's Manual, dated 21 May 1993, provides instructions and procedures for operation of the PASBA2 inpatient data retrieval program in all Army medical treatment facilities. c. The IPDS records contain information protected under the Privacy Act of 1974. It is essential that you safeguard this data. As a precaution, the chief of Patient Administration Division (PAD) must install a password program before enabling users access to PASBA2.

Continue with Lesson Exercises

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EXERCISES, LESSON 4 INSTRUCTIONS: Complete the following exercises by marking the lettered response that best answers the question, or by finishing the incomplete statement, or by writing the answer in the space provided at the end of the question, or by extracting data from an Inpatient Treatment Record Cover Sheet (ITRCS) and coding the A&C Form provided. After you have completed the exercises, turn to "Solutions to Exercises" at the end of the lesson and check your answers.

1. The purpose of the Individual Patient Data System is to provide: a. _____________________________ _____________________________ _____________________________. b. c. _____________________________. _____________________________ _____________________________. d. _____________________________ _____________________________ _____________________________.

2. The purposes of DA Form 2985 (Admission and Coding Information) are: a. b. _____________________________. _____________________________.

3. Because it is a dual purpose form, DA Form 2985 is known as the ___________ Form.

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4. Fields on DA Form 2985 have been arranged so that most of the demographic and administrative data are on page __________ of the three-page form.

5. Codes on the A&C Form must be written legibly. Alphabetical characters must be printed as ___________letters. Zero must always be written __________.

6. Nonautomated sites/hospitals should complete applicable fields of the A&C Form in an original and _________legible copies at the time of admission and maintain these copies in a suspense file while the patient remains in an inpatient status.

7. At the time of disposition, copies of the patient's A&C Form are removed from the suspense file and applicable fields on ______ are completed by the Admissions and Dispositions office.

8. After disposition, the A&C Form is forwarded to the _______ _____________________for filing in the patient's terminal digit file folder to await completion of the Inpatient Treatment Record (ITR).

9. Upon completion of the Inpatient Treatment Record (ITR), the original and copies of the A&C Form are removed from the patient's terminal digit file folder and ______ ___ are completed by the Medical Records Administration Branch personnel.

10. In the following example, 1. REPORTING MTF is a ________ on the A&C Form.

1. REPORTING MTF
1 2 3 4 5 6

A

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11. In the following example, blocks 1 through 6 are__________ ____________ on the A&C Form. 1 2 3 4 5 6

A
12. An entry in the following example would be the first _________ on the patient's Inpatient Treatment Cover Sheet (DA Form 3647). 1. REGISTER NUMBER

13. The MTF code for Brooke AMC, Fort Sam Houston, TX is ___________.

14. The original A&C Form is filed in the patient's ___________ __________.

15. One legible copy of the A&C Form and a copy of the Inpatient Treatment Record Cover are forwarded to _________________ ______________________________for input into the IPDS data base.

16. Information from DD Form 1380, U.S. Field Medical Card (FMC) is encoded on DA Form 2985 (A&C Form) only when the FMC reflects a__________________________ or when it represents ___________________________________________________.

17. The Automated Quality of Care Evaluation Support System (AQCESS) or the Composite Health Care System (CHCS) Individual Patient Data System (IPDS) record transmittals must be submitted ________ each month.

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18. A monthly transmittal tape should be created on or about _______________. An ______________transmittal tape should be created on or about the 15th working day of each month.

19. Nonautomated sites requiring data reduction services by the U.S. Army Patient Administration Systems and Biostatistical Activity (PASBA) should send ______________________________ _____________________to PASBA.

20. The magnetic tape/cassette transmitting IPDS records to PASBA should be forwarded by _________________or _____ ______________ mail.

INSTRUCTIONS: For exercises 21 and 22, the use information which has been provided or recorded on DA Form 3647 (Inpatient Treatment Record Cover Sheet) to code data on DA Form 2985 (A&C Form) for the two patients listed. In reality, some information on page 1 would be coded during the admission. THIS IS A TRAINING EXERCISE.

21. Major Joann M. Birchett, a white (not hispanic) patient administration officer, was born on 1 April 195X. Below is her Inpatient Treatment Record Cover Sheet.

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Figure 4-5; DA Form 3647, Inpatient Treatment Record Cover Sheet

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Figure 4-6; DA Form 2985 for Exercise 21 (continued).

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Figure 4-7; DA Form 2985 for Exercise 21 (continued).

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Figure 4-8; DA Form 2985 for Exercise 21 (concluded).

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22. Below is the ITRCS for Master Sergeant Christopher M. Kraft, a black (not hispanic) patient administration specialist, born on 22 April 196X. Following surgery on 20 Nov 9X, MSG Kraft was assigned to the Orthopedic Clinic Service for 11 days. He returned to the Rheumatology Clinic Service and remained there until his disposition.

Check your answers

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Figure 4-9; DA Form 3647, Inpatient Treatment Record Cover Sheet

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Figure 4- 10; DA Form 2985 for Exercise 22 (continued).

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Figure 4-11; DA Form 2985 for Exercise 22 (continued).

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Figure 4-12; DA Form 2985 for Exercise 22 (concluded).

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SOLUTIONS TO EXERCISES, LESSON 4 1. a. b. c. d. Data for planning, managing, and evaluating the AMEDD medical care system. Data for medical and epidemiological research. Rapid data retrieval in response to inquiries from HQDA, HSC, OTSG, DOD, and other authorized organizations and individuals. Management reports and retrieval of special data for the hospital commander and his staff. (para 4-1b(1) -- (4)) To be used as a patient admission information document. To be used as a coding transcript. (para 4-4a) A&C or admissions and coding. (para 4-4a(note)) One. (para 4-4a) Capital block, Ø. (para 4-5b) Two. (para 4-5a & c) Page 1. (para 4-5d) Medical Records Administration Branch. (para 4-5e) Pages 2 and 3. (para 4-5f) Field. (para 4-3b) Columns. (para 4-3c) Item. (para 4-3d) A14Ø1. (para 4-7b and Table 4-1) ITR (Inpatient Treatment Recort). (para 4-5g) The U.S. Army Medical Department Center and School, Patient Administration Systems and Biostatistics Activity (PASBA). (para 4-5h)

2.

a. b.

3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

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16. 17. 18. 19. 20. 21.

Final disposition, CRO. (para 4-86a) Twice. (para 4-108a) The 4th working day of each month, interim. (para 4-108a(1) -- (2)) A fully completed A&C Form plus DA Form 3647 (ITRCS). (para 4-108f(1)) First class, priority. (para 4-108c) BIRCHETT, Joann M.

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Figure 4-13; DA Form 2985 for Exercise 21 (continued).

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Figure 4-14; DA Form 2985 for Exercise 21 (continued).

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Figure 4-15; DA Form 2985 for Exercise 21 (concluded).

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Figure 4-16; DA Form 2985 for Exercise 22 (continued).

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Figure 4-17; DA Form 2985 for Exercise 22 (continued).

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Figure 4-18; DA Form 2985 for Exercise 22 (concluded).

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COMMENT SHEET SUBCOURSE MD0753 Medical Records Administration Branch I EDITION 101

Your comments about this subcourse are valuable and aid the writers in refining the subcourse and making it more usable. Please enter your comments in the space provided. ENCLOSE THIS FORM (OR A COPY) WITH YOUR ANSWER SHEET ONLY IF YOU HAVE COMMENTS ABOUT THIS SUBCOURSE.. FOR A WRITTEN REPLY, WRITE A SEPARATE LETTER AND INCLUDE SOCIAL SECURITY NUMBER, RETURN ADDRESS (and e-mail address, if possible), SUBCOURSE NUMBER AND EDITION, AND PARAGRAPH/EXERCISE/EXAMINATION ITEM NUMBER.

PLEASE COMPLETE THE FOLLOWING ITEMS:
(Use the reverse side of this sheet, if necessary.) 1. List any terms that were not defined properly.

2.

List any errors. paragraph error correction

3.

List any suggestions you have to improve this subcourse.

4.

Student Information (optional)

PRIVACY ACT STATEMENT (AUTHORITY: 10USC3012(B) AND (G))
PURPOSE: To provide Army Correspondence Course Program students a means to submit inquiries and comments.

Name/Rank SSN Address E-mail Address Telephone number (DSN) MOS/AOC

USES:

To locate and make necessary change to student records. VOLUNTARY. Failure to submit SSN will prevent subcourse authors at service school from accessing student records and responding to inquiries requiring such follow-ups.

DISCLOSURE:

U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

Fort Sam Houston, Texas 78234-6130

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