Sick Call & Medical Documentation

DD Form 689

Individual Sick Call Slip

Individual Sick Call Slip

Used for a patient who requests or receives medical/dental evaluation or treatment at an Amry Medical Treatment Facility, means of communication between medical personnel and the patient’s commander

SF 600

Chronological Record of Medical Care

Chronological Record of Medical Care

Basic form used to document the chronological record of outpatient treatment

HIPAA

Health Insurance Portability and Accountability Act

Patient Confidentiality

HIPPA is a federal law protecting the privacy of patient specific health care information and providing the patient with control over how this information is used and distributed

Access to medical information is given to…

The patient, patient care personnel, medical researchers, medical educators

Patient’s care can be requested through…

Law, hospital accreditation, authorized by the patient

SOAP

Subjective Objective Assessment Plan

Subjective entry to SOAP note

Patient data, history of present illness, past history

Objective entry to SOAP note

Vital signs, physical examination findings

Vital Signs

Height

Weight

Pulse

Respiratory rate

Blood pressure

Temperature

Oxygen saturation

ADTMC

Algorithm Directed Troop Medical Care

MHS Genesis

Military Health System

FDLMP

First Day of Last Menstrual Period

HPI

History of Present Illness

PMH

Past Medical History

PSH

Past Surgical History

Soc Hx

Social History

Quarters

Restriction and rest in the patient’s place of domicile, this freedom of movement also extends to the dining facility and medical treatment facility, does not exceed 72 hours, may not perform military duties

Bedrest

The patient is restricted to their bed, with allowances for necessary travel to the dining facility and latrine, may not perform military duties

Patient Data for Subjective

Age, sex, race and FDLMP

Breaking Profiles

Profiles and duty limitations are only strong recommendations issued to command channels by medical authorities, commanders may decide the successful completion of a mission requires a Soldier “break” their profile, in such an instance, the commander takes responsibility for his actions