This form is directly involved with the Adult Preventative form and builds upon that form as well.
The Chronological Record of Medical Care, SF 600, is a continuous record of a patient’s medical history. The SF 600 form is used in all outpatient care and filed in the HREC or OREC.
This type of record has almost everything in it. It even includes a recording of all visits including those that result in referrals to other MTFs.
The providers or staff who are making entries into the SF 600 will sign the entry and include their identification information. This will include either hand-printed, typed, or stamped:
- Full name
The SF 600 makes evaluation much easier for the provider. It reduces the correspondence necessary to obtain medical records. If the SF 600 is used appropriately, it will eliminate unnecessary reordering of diagnostic procedures. The SF 600 serves as a permanent record of medical evaluations and treatments in a patient’s health records.
How to fill-out and complete the SF 600
When you are filling out an SF 600, it can be typewritten. However most of the time it is handwritten in black or blue ink pens.
The SF 600 has all the completed patient identification data. You simply must type or stamp the date in DD/MM/YY order with the name and address of the activity responsible for the entry.
The staff must also use both sides of the SF 600 sheets. If the person is being seen at a different MTF it is not necessary to start a new SF 600 sheet. Just continue on with the same sheet and where it was left off.
If the member has an SF 600 that still has many more lines available right before their time of PCS, the provider will need to stamp the designation and the location of the receiving MTF below the last entry and use the rest of the page to record subsequent visits.
If the back of an SF 600 is not going to be used you will need to cross out and add in the words “No further entries” in the middle of the form.
The SF 600 includes the following information:
- Duration of illness or injury
- Physical findings
- Clinical course
- Results of laboratory or other special examinations
- Treatment and operations
- Physical fitness
The provider is welcome to use the subjective, observation, assessment, and plan (S.O.A.P note) format as long as the list from above is all included.
The duty of the provider is to make sure to record each visit and the complaint that is described by the member. The provider must even record if the patient leaves before even being seen.
The SF 600 entries also include other information that may be relevant:
- Imminent hospitalization
- Special procedures and therapy
- Sick call visits
- Injuries or poisonings
- Line of duty inquiries
- Binnacle list and sick list
- Reservist check-in and check out statements
What is imminent hospitalization in Navy Medicine SF 600?
Imminent hospitalizations and admission notes can be made on the SF 600. However, it is recommended to include this information in the SF 509, Medical Record Progress Report.
The SF 509 form is oftentimes used for inpatient admissions and is filed in the patient’s IREC (inpatient records).
The record referred or postponed inpatient admissions in the SF-600.
What is the special procedures and therapy in Navy Medicine SF 600?
When a patient is seen several times for special procedures or therapy such as physical or occupational support, renal dialysis, or radiation, this must be noted in the SF 600 with a recording of the progress statements.
Initial notes, interim progress notes, and any other summaries that you record on any other authorized forms are okay, but you should reference it back to the SF 600.
A final summary is recommended when special procedures or therapies have ended. This summary should include the results and the treatment given. It should also provide any reactions, progress is noted, conditions on discharge and any other pertinent observations noted during care.
What is the sick call visits in Navy Medicine SF 600?
This is for sick calls. entries here will be made on the SF 600 reflecting the complaints or conditions presented, pertinent history, treatment rendered, and dispositions.
What is the injury or poisoning in Navy Medicine SF 600?
If there is a case of injury or poisoning, a record of the duty status of the member at the time that this has occurred and the circumstances of the occurrence is required according to the guidelines in BUMEDINST 6300.3 series, Inpatient Data System.
What is the line-of-duty inquiries in Navy Medicine SF 600?
When a member gets injured to a point that there might be permanent disability or an injury that results in the inability to perform the duty for a period beyond 24 hours, an entry will be made about the line-of-duty misconduct.
When entering this into the SF 600, the caregiver must provide the:
- Time of injury
- Name of the persons involved
- Circumstances surrounding the injury
The reason for the line-of-duty inquiry is to determine whether the injury is the result of misconduct. Guidance on the line of duty inquiries is located in the Manual of the Judge Advocate General (JAGMAN).
What is the seriously ill/very seriously ill list (SI/VSI) list in Navy Medicine SF 600?
This is where you place personnel who are ill or injuries are severe on the SI/VSI list according to the MILPERSMAN 421-0100.
What is special-hypersensitivity in Navy Medicine SF 600?
Providers are also required to indicate on the SF 600 any hypersensitivity to drugs or chemicals. This should be on a separate SF 600 marked “SPECIAL HYPERSENSITIVITY” at the bottom of the page. When recording hypersensitivity the provider also must record it on the appropriate entries in all the different forms as well.
|Dental exam report
|Dental treatment report
|HREC, OREC, DREC
|DD Form 2766
|Adult preventative and chronic care flow sheet