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

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