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

(4) A complete, current report of medical examination will be included in the narrative summary completed by the
physician and recorded on SF 502.
(5) When an enlisted member is being evaluated because of a psychiatric condition, a copy of DA Form 2-1
(Personnel Qualification Record-Part II) should be reviewed by the MEB and attached to the board proceedings as
enclosure 3.
(6) For patients who are unlikely to return to duty, the member’s commander will be contacted and asked to provide
a special letter of evaluation which describes the member’s recent duty performance. This letter will be evaluated by
the MEB and attached to the board proceedings as enclosure 4.
b. Except as required elsewhere in this regulation, copies of DA Form 3947 and enclosures will be distributed as
shown in table 7-1. If mental incompetency is found, one additional copy will be prepared for the U.S. Army Finance
and Accounting Center. (See para 7-13.) All MEB members will sign the original and initial duplicate copies of the
proceedings. However, if mental incompetency is found, all copies must be signed by each member. The copy of SF
502 that becomes part of the medical record will be annotated by the attending physician to show final disposition of
the patient. The original DA Form 3947 is the hospital copy of record.
c. MEBs referred to a PEB require special care in recording MEB proceedings to ensure clarity and completeness.
PEBs usually evaluate an individual’s impairments primarily on the basis of the records. Review and appeal boards use
only the records and never see the patient. It is imperative, therefore, that entries be worded carefully so that they are
both informative and precise. The entry on SF 502 describing the patient’s present condition should include an accurate
description of the limitations imposed by each impairment listed. If applicable, the entry should also include a
discussion of the combined effect of all impairments.
7–9. Preparing medical evaluation board narrative summaries
The recommended format for an MEB narrative summary is provided below.
a. Baseline documentation. At the beginning of the MEB, the following will be recorded:
(1) The signatory physician’s specialty.
(2) The clinical department/service.
(3) The MTF and its location.
(4) Reason for doing the MEB (for example, physician-directed, command-directed).
(5) Soldier’s eligibility for MEB.
(6) Military history.
(a) Date of entry into Service.
(b) Estimated termination of Service.
(c) Administrative actions ongoing, pending, or completed (for example, courts-martial, selective early retirement,
bars, retirement or separation dates).
(7) Chief complaint stated in Soldier’s own words.
(8) History of present illness. Exact details, including pertinent dates regarding injuries, how incurred, and a
statement of the final LD determination, if available.
(9) Past medical history.
(a) Past injuries and illnesses.
(b) Prior disability ratings (for example, given by the VA).
(c) Past hospitalizations and relevant outpatient treatment, including documentation of diagnosis and therapy,
pertinent dates, and location should be listed.
(d) Illnesses, conditions, and prodromal symptoms, existing prior to service conditions.
b. Physical examination. A complete physical examination must be recorded in the MEB. Selected specialty-related
considerations and guidelines follow.
(1) Cardiology.
(a) Results of special studies to support and quantify the cardiac impairment should be noted (for example, treadmill
and thallium stress tests, angiography, and other special studies).
(b) It is imperative that the Functional Therapeutic Classification of the cardiac condition be included. Either the
New York or Canadian classification system may be used.
(2) Gastroenterology. Soldiers with fecal incontinence should have recorded findings of rectal examination (for
example, digital exam, manometric studies as indicated and radiographic studies). The degree and frequency of the
incontinence should be noted, as well as the incapacitation caused by the condition.
(3) Neurosurgery.
(a) In vertebral disc problems, radicular findings on physical examination should be supported by laboratory studies
such as computerized axial tomography scan, MRI, or electromyography. In cases where surgery has been performed,
both pre- and post-operative deep tendon reflexes should be documented.
(b) In head injuries, neuropsychiatric assessment should be accomplished. Results of any clinically indicated
neuropsychological testing should be included.
AR 40–400 27 January 2010
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