Patient Administration - Army Publishing Directorate - U.S. Army

Patient Administration - Army Publishing Directorate - U.S. Army Patient Administration - Army Publishing Directorate - U.S. Army

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(b) Patient information. The following will be provided when reporting EC patient information: 1. Full name. 2. Rank/service. 3. Social security number. 4. Sex. 5. Unit. 6. Admission date. 7. Register number. 8. Date of birth. 9. Source of admission 10. External cause of injury. 11. MTF of initial admission. 12. Date of initial admission. 13. Injury date/location. 14. Diagnosis. 15. Comments, to include clinical updates, treatment and transfer plans, treatment occurring at civilian facilities for patients in absent sick status, changes in status to include SI/VSI and condition changes, MEB/PEB progress reports, and so forth. (c) EC reports. The PASBA will prepare and disseminate EC reports as required. (3) MASCAL and Stability Operations and Support Operations patients. (a) MTF personnel will immediately notify the USAMEDCOM PAD or SDO (after duty hours) that a MASCAL or other significant incident has occurred that will generate high visibility and/or public interest in casualty information. The following notification will be made: 1. MTF personnel will notify the USAMEDCOM PAD at DSN 471-6615/6113 during duty hours (0730–1630, CT). After duty hours, the USAMEDCOM SDO will be notified at DSN 471-8445. Commercial area code and prefix is (210) 221-8445. 2. After duty hours, the USAMEDCOM SDO will contact the OTSG/OPSCENTER 21 Desk Officer at DSN 761- 8052 who will make appropriate notifications. In addition, the SDO will call the USAMEDCOM PAD representative as listed in the USAMEDCOM notification roster. 3. MTF notification to the USAMEDCOM will include the following information: Nature, date, and time of the incident; expected and actual number of patients; number of patients treated and released, admitted, dead on arrival, and hospital deaths; number of patients transferred to or admitted at other/civilian facilities; number of SI/VSI patients; other significant information such as public figures involved or other issues of public interest. (b) Notification procedures (apply to both MASCAL and Stability Operations and Support Operations (operations other than war) patients). MTF personnel will furnish the information listed below to PASBA through the Joint Patient Tracking Application (JPTA) or PARRTS within 24 hours of patient admission, change in status, or disposition. Until an Armed Forces Health Longitudinal Technology Application interface between MTFs and the JPTA database is developed, data can be entered directly into JPTA or PARRTS. For information on establishing a JPTA account or assistance in using JPTA, contact the JPTA Help Desk at (703) 578-8553 or by email at jpta@deploymenthealth.osd. mil. 1. Full name. 2. Rank/service. 3. Social security number. 4. Sex. 5. Unit. 6. Admission date. 7. Register number. 8. Date of birth. 9. Source of admission. 10. External cause of injury. 11. MTF of initial admission. 12. Date of initial admission. 13. MTF transferred to. 14. Diagnosis. 15. Disposition type and date. 16. SI/VSI status. 17. Comments to include clinical updates, treatment and transfer plans, treatment occurring at civilian facilities for 50 AR 40–400 27 January 2010

patients in absent sick status, changes in status to include SI/VSI and condition changes, MEB/PEB anticipated/ progress reports, anticipated convalescent leave, also-an-EC patient, and so forth. (c) MTFs will continue to provide updates on a periodic basis as required. Initially, in any given contingency/ incident, updates will be required more frequently, even several times per day. Thereafter, daily updates will be prepared until it is determined that there is no further need. (d) The PASBA will maintain the special interest patient database and will prepare and disseminate special interest reports on patients involved in MASCAL and other significant incidents as required. (e) USAMEDCOM PAD, in conjunction with PASBA, will be responsible for disseminating information to individuals/organizations with a legitimate need to know who do not have access to the patient database. Additionally, USAMEDCOM PAD/PASBA will prepare executive summaries on the status of patient management activities as required. (4) GO reporting. (a) Outpatient care. As the principal advisor to the Army Chief of Staff, TSG must know when GOs are under medical care for potential career-threatening conditions. Routine reporting for GO admissions was addressed above. However, TSG must be informed when GOs are seen as outpatients for conditions that could affect their ability to remain on AD. (b) Notification procedures. MTF commanders will personally report to TSG, by electronic means, GO outpatients being seen for conditions that could affect their ability to continue performing current duties. MTF commanders must use their judgment to discern potentially unfitting conditions that meet this criteria, with the admonition that erring should be on the side of over-reporting. "Rule out" diagnoses of sufficient potential severity should definitely be reported even though confirmation tests are ongoing. Information transmitted should include the following: 1. Facility name. 2. Full name. 3. Rank/service. 4. Social security number. 5. Diagnosis or tentative diagnosis. 6. Attending physician. 7. Treatment plan. (c) The OTSG Executive Officer will notify the General Officer Management Office of the admission, change in condition, or discharge of active duty GOs. The notification will be limited to the GO’s name, organization, MTF name, and the GO’s condition in broad terms. The details reported in the executive summary will be available for TSG’s information. (d) Electronic reports should be addressed to TSG, the Deputy Surgeon General, and the appropriate Regional Medical Command commander. 6–4. Deceased persons a. All deaths (except civilian emergency) occurring at an Army MTF must be reported to the CAC. A certificate of death is prepared for each deceased person. The MTF commander establishes the policy based upon a need-to-know including those required by AR 600-8-1 and AR 638-2. The CAC must be notified that a mortuary affairs benefits counselor is required to provide mortuary affairs benefit information to the person authorized to direct disposition-ofremains. This briefing must occur prior to requesting a relative of the decedent to complete an SF 523A (Medical Record-Disposition of Body). When the remains are unclaimed, the CAC is responsible for coordinating and taking disposition-of-remains actions as prescribed in AR 638-2. All notifications are recorded on DA Form 3894 (Hospital Report of Death). All information pertaining to deceased notification will be immediately passed to the responsible CAC. Information will be safeguarded to prevent inappropriate disclosure (AR 360-5). The medical officer in attendance at the time of death or in the circumstance of DOA, the medical officer who pronounces a person dead, will initiate DA Form 3894 and forward it, ordinarily by hand carry, to the patient administrator or administrative officer of the day. For stillbirths or fetal deaths within the United States, DA Form 3894 will be initiated only when a death certification and burial permit are required by local law. For stillbirths or fetal deaths outside the United States, DA Form 3894 will be initiated only when a death certification and burial permit are required by local law or when the remains will be prepared at an Armed Forces mortuary. The physician in attendance at the time of delivery or abortion is responsible for initiating and forwarding DA Form 3894 to the patient administrator. DA Form 3894 is available on the APD Web site (www.apd.army.mil/). b. AR 638-2 provides guidance for preparation and disposition of remains and mortuary affairs benefits. DA Form 3910 (Death Tag) is prepared in triplicate and affixed to the deceased. Local laws of the area in which an MTF is located may impose requirements with regard to handling remains. The MTF commander should obtain disposition of remains guidance from the CAC commander. DA Form 3910 may be obtained through normal distribution channels. c. Laws governing the registration of stillbirths or fetal deaths (completion of fetal death certificates) vary among the States and overseas countries. Fetal remains will be disposed of according to local law. The disposition desired by the person authorized to direct the disposition of remains will be recorded and will become a part of FN 40-400p (AR AR 40–400 27 January 2010 51

(b) <strong>Patient</strong> information. The following will be provided when reporting EC patient information:<br />

1. Full name.<br />

2. Rank/service.<br />

3. Social security number.<br />

4. Sex.<br />

5. Unit.<br />

6. Admission date.<br />

7. Register number.<br />

8. Date of birth.<br />

9. Source of admission<br />

10. External cause of injury.<br />

11. MTF of initial admission.<br />

12. Date of initial admission.<br />

13. Injury date/location.<br />

14. Diagnosis.<br />

15. Comments, to include clinical updates, treatment and transfer plans, treatment occurring at civilian facilities for<br />

patients in absent sick status, changes in status to include SI/VSI and condition changes, MEB/PEB progress reports,<br />

and so forth.<br />

(c) EC reports. The PASBA will prepare and disseminate EC reports as required.<br />

(3) MASCAL and Stability Operations and Support Operations patients.<br />

(a) MTF personnel will immediately notify the USAMEDCOM PAD or SDO (after duty hours) that a MASCAL or<br />

other significant incident has occurred that will generate high visibility and/or public interest in casualty information.<br />

The following notification will be made:<br />

1. MTF personnel will notify the USAMEDCOM PAD at DSN 471-6615/6113 during duty hours (0730–1630, CT).<br />

After duty hours, the USAMEDCOM SDO will be notified at DSN 471-8445. Commercial area code and prefix is<br />

(210) 221-8445.<br />

2. After duty hours, the USAMEDCOM SDO will contact the OTSG/OPSCENTER 21 Desk Officer at DSN 761-<br />

8052 who will make appropriate notifications. In addition, the SDO will call the USAMEDCOM PAD representative as<br />

listed in the USAMEDCOM notification roster.<br />

3. MTF notification to the USAMEDCOM will include the following information: Nature, date, and time of the<br />

incident; expected and actual number of patients; number of patients treated and released, admitted, dead on arrival,<br />

and hospital deaths; number of patients transferred to or admitted at other/civilian facilities; number of SI/VSI patients;<br />

other significant information such as public figures involved or other issues of public interest.<br />

(b) Notification procedures (apply to both MASCAL and Stability Operations and Support Operations (operations<br />

other than war) patients). MTF personnel will furnish the information listed below to PASBA through the Joint <strong>Patient</strong><br />

Tracking Application (JPTA) or PARRTS within 24 hours of patient admission, change in status, or disposition. Until<br />

an Armed Forces Health Longitudinal Technology Application interface between MTFs and the JPTA database is<br />

developed, data can be entered directly into JPTA or PARRTS. For information on establishing a JPTA account or<br />

assistance in using JPTA, contact the JPTA Help Desk at (703) 578-8553 or by email at jpta@deploymenthealth.osd.<br />

mil.<br />

1. Full name.<br />

2. Rank/service.<br />

3. Social security number.<br />

4. Sex.<br />

5. Unit.<br />

6. Admission date.<br />

7. Register number.<br />

8. Date of birth.<br />

9. Source of admission.<br />

10. External cause of injury.<br />

11. MTF of initial admission.<br />

12. Date of initial admission.<br />

13. MTF transferred to.<br />

14. Diagnosis.<br />

15. Disposition type and date.<br />

16. SI/VSI status.<br />

17. Comments to include clinical updates, treatment and transfer plans, treatment occurring at civilian facilities for<br />

50 AR 40–400 27 January 2010

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