DD Form 689
Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment at an Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's commander
...
68W LIMITED PRIMARY CARE QUESTIONS AND ANSWERS
DD Form 689 - answer Individual sick call slip that initiates the sick call process
Used for patient who requests or receives medical/dental evaluation or treatment at an Army Medical Treatment Facility (MTF)
used as a means of communication between medical personnel and the patient's commander
SF 600 - answer Chronological Record of Medical Care
form used to document the chronological record of the patient's treatment
Should include:
- Date and time of visit
- Medical Treatment Facility
- Signature of person making entry
Correction procedures for an entry error - answer Draw a single line through the information, write "Error," and your initials
If you have finished the documentation and decide later information needs to be changed:
- add correct information
- reason for change - date and initial
- Do not skip lines or leave any spaces above signature
HIPAA - answer Health Insurance Portability and Accountability Act a federal law protecting the privacy of patient-specific health care information
Access to patient's medical information may be given too... - answer - the patient
- patient care personnel
- medical researcher
- medical educators
Exceptions for those that can access a patient's medical information are... - answer - if access is court ordered by law
- if access if needed for hospital accreditation
- if access is authorized by the patient via a written document
Disclosure of medical information is handled by... - answer the PA or the patient administrator (PAD)
History Taking Techniques - answer 1) Observation - begins when patient walks through the door
2) Listening - will help you find out the problem
3) Open-ended questions - helps you get more complete and accurate information 4) Provider obstacles - keep a good attitude and assume every patient has a legitimate complaint
5) Patient obstacles - patient's w/o medical experience will very often request specific diagnostic
studies, therefore, we must gain their trust
6) Obtain a thorough history
7) Maintain an index of suspicion
8) Consider the mechanism of injury
Triage - answer Triage is about looking for signs and symptoms that could lead to serious illness or even death
You may decrease the likelihood of overlooking these conditions by maintaining an index of suspicion based on the presenting symptoms and by obtaining accurate vital signs on each and every patient
Techniques for Identifying Critically Ill Patients - answer - Obtain the chief complaint
- Identify patients with signs and symptoms that have increased potential for complications
- promptly obtain vital signs
- perform a physical exam and report findings to medical provider
Initiating the Sick Call Process - answer 1) Patient will obtain a DD Form 689., an individual sick slip, which will ensure accountability of the soldier is maintained both at the MTF and with patient's unit
2) a combat medic will be assigned to sign in all patients in a daily disposition log
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