PWS_Inpatient_Transcription_Service.doc

PERFORMANCE WORK STATEMENT

MEDICAL TRANSCRIPTION SERVICE

DAVID GRANT MEDICAL CENTER

TRAVIS AFB, CA

14 Mar 18

TABLE OF CONTENTS

SECTION NO. AND TITLE

PAGE NO.

I.

Description of Service

II.

Service Delivery Summary

III.

Government-Furnished Property and Services

IV.

General Information

V.

Appendices

A. Workload Estimates & Historical Data

B. Turnaround Time

C. Standardized Abbreviations, Acronyms and

D. DGMC Do not Use Abbreviations

E. Template Samples

F. Daily Report Format

G. Applicable Instructions, Directives and Regulations 29

I. DESCRIPTION OF SERVICES

1. The objective of this service is to provide the, David Grant Medical Center, Travis Air Force Base (hereinafter referred to as the MTF) with the most accurate, cost-effective, timely, medical off-site transcription services. MTF reports are comprised of specialized vocabularies and encompass a variety of subjects in the field of medicine and surgery. These vocabularies include but are not limited to: ambulatory care, anesthesiology, cardiology, dentistry, dermatology, drug and alcohol treatment, endocrinology, general medicine, gastroenterology, general surgery, geriatrics, gynecology, hematology, immunology, internal medicine, neurology, neurosurgery, nuclear medicine, oncology, ophthalmology, oral surgery, orthopedics, otolaryngology, otorhinolaryngology, pathology, psychiatry, psychology, plastic surgery, pulmonary, renal, rheumatology, spinal cord injury, thoracic surgery, transplant and urology and vascular. Material is dictated by a variety of clinical staff and requires adaptation to variations in accents, speech, tone, voice volume, delivery, pronunciation, and enunciation. Transcription services will be in compliance with Joint Commission Standards and Air Force Health Services Inspection Standards (HSI).

1.1. The Contractor shall provide the management, supervision, personnel qualifications, skills and abilities, transportation, and other items and services necessary to perform medical transcription services dictated by the MTF healthcare providers. The Contractor shall utilize best standardized industry standards and comply with military directives and parameters, to produce efficient and accurate transcription service.

2. System: Dictation will reside on the Contractor’s dictation system. Verification code will be provided at the time of dictation. Transcribed reports will be returned through a secure, high-speed Internet connection web interface utilizing Air Force approved client software such as Internet Explorer or Google Chrome. Contractor will provide all necessary hardware and software, not currently owned by the MTF, and ensure all hardware and software installed and/or connected to the MTF network is in compliance with all applicable DoD, Air Force, AMC and base directives to include:

a) Meet Air Force and Defense Health Agency Information Assurance requirements including completion of the Risk Management Framework (RMF) process and/or obtaining software approvals as needed.

b) Web sites must not make use of active x controls or other embedded software other than Java

c) All web connections will be accomplished via the USAF proxy server

d) In order to comply with Department of Defense Network Security Regulations and HIPAA rulings, contractor will provide an encryption engine for all 60 MDG data traffic. This engine will conform using 256 bit AES SSL Encryption FIPS 140-2 compliant standards and will use the Secure Socket Layering protocol for data transmission.

e) Contractor shall pay for all connect/toll charges for dialing any and all MTF provided phone numbers. The Contractor shall notify the MTF’s Inpatient Records Department immediately of any equipment or connections that are not functioning properly and could adversely affect dictation or transcription.

f) If MTF cannot print signed notes from Contractor’s website due to DoD security/firewalls, Contractor will utilize AMRDEC Safe Access File Exchange (SAFE)

g) Contractor shall provide a backup plan in case of loss of remote connectivity to the base due to terrorist activity or other natural disaster.

https://safe.amrdec.army.mil/safe/Default.aspx to send daily signed notes/files to medical records administrative staff appointed to upload into the current DoD inpatient electronic health record system. The report needs to be able to interface with the current DoD Electronic Medical Record (EMR) systems Essentris (Inpatient EMR) and ALTHA (Outpatient EMR) used at Travis AFB after provider reviews and signs report for accuracy and legibility.

f) Contractor shall provide a Manual of Operations within 7 days of award that serves as training material for users of the dictation system. Instructions for starting and ending a dictation shall be a component of the system. The manual shall be available in electronic form for ease of distribution.

2.1 Orientation Period: To ensure a smooth transition in the change of work effort from current contract, the service provider shall begin and complete all of the following requirements within the 30 calendar days prior to operational performance start date. The purpose of this orientation period is to:

a. Become thoroughly familiar with work requirements.

b. Complete personnel requirements (work force) including the hiring of personnel to ensure satisfactory performance beginning on the operational performance start date.

c. Complete contractor provided employee-training requirements

d. Register users with usernames/password to access contractor’s system

e. Complete the development of necessary work plans/procedures.

2.2 Transition Period: The Contractor shall assume full responsibility for all functions identified in the Performance Work Statement 30 calendar days prior to operational performance start date. The service provider shall ensure full manning is available at operational performance start date. At the end of the 30-day transitional period the contractor’s performance shall meet the Service Delivery performance threshold.

3. Requirements.

3.1. Minimum Qualifications: Transcriptionists will have sufficient education and experience that may have certificates in Registered Healthcare Documentation Specialist (RHDS) and/or Certified Healthcare Documentation Specialist (CHDS) so that the objective of this PWS is met. The contractor shall ensure that the supervisor and alternate have current and valid professional certification from American Association of Medical Transcriptionists (AAMT).

4.1. Report Quality: Reports must be of the highest professional quality to ensure at least 98% accuracy with respect to all errors. An error includes, but not limited to, medical word misuse, omitted dictation, misspellings, most demographics errors, formatting errors, capitalization, punctuation, and other minor style and grammar errors.

4.2. TAT (Turn-around-time): TAT is the difference in time between the time the author hangs up at the conclusion of dictating into the dictation system, and the time the Contractor's completed transcribed reports are received by the MTF. The Contractor shall type all dictated reports within 24-clock hours of the dictated time, including weekends and holidays. If failure to meet the 24-clock hour turnaround is due to circumstances beyond the Contractor's control, the Contractor is expected to catch up with the dictation workload within a reasonable amount of time as defined by the amount of backlogged reports. Specifically, the contractor will be expected to surge to accomplish up to 100% of the normal daily workload. See

Appendix B.

4.3. Surges: During federal holidays, military deployments, minimal manning days and Government system failures, workload may fluctuate (decrease or increase). The Contractor will be required to maintain the standard, 24-hour turn around time for completion of reports during normal workflow fluctuations.

4.4. Corrected Reports TAT: Incorrect routine reports shall be corrected and retransmitted within four (4) hours of notification by the MTF FRED (Functional Requirements Evaluator Designee). STAT reports shall be corrected and retransmitted within one (1) hour of notification by the MTF FRED. Corrected reports shall be flagged as corrected when retransmitted. The contractor shall provide a report to MTF of all corrected reports monthly either through their website to access or directly to appointed point of contact.

5. Preparation and Report Formats.

5.1 Line Accounting: the Contractor will use the AFI 41-210 Tricare Operations and Patient Administration Functions in determining narrative lines, form-style lines, block lines and will use the templates provided. Suggested counting and reporting: margins should be adjusted to ensure full lines that average 80 strokes (characters), narrative lines of 80 strokes should average 13 words. Count each typed line with six words or more as a line; any narrative line with five words or less is not counted. Form-style typing: count each line with 2 or more names, dates or words as one line. Physician signature elements are counted as two lines when a two-line signature element is used, and counted as one-line when a one–line signature element is used. Patient identification data is counted as two lines.

5.2 The Contractor will provide a daily log report to include job number, total line counts, dictated time, type of report, date and time sent to provider for review. The report must be submitted to FRED each month for billing purposes and a final end of month report.

5.3 The Contractor will generate an automated e-mail notification directly to providers notifying them of any pending or overdue reports awaiting review or signature. In addition, the contractor will also provide a report of the e-mail notification to the Section Chief and Director of Medical Records. See Appendix F for format.

5.4 Report Length: The length of each report shall vary according to the type of medical report required. The text is single spaced with double space between paragraphs. No report shall include any text other than what was dictated; except for formatting as instructed by the MTF, comments or questions must be sent as separate correspondence referencing the dictation system reference number.

5.5. Formatting Information: The Contractor shall ensure all headers and footer information complies with MTF standards as listed below:

5.6. Header Information: Each document shall include the specified header conforming to the standard provided by the MTF for that type of document. This header includes the document type, date of exam, the document author, dictation date, attending physician, when dictated.

5.7. Footer information: Footer information shall be typed on one-line two spaces below the end of the body of the transcribed report and shall include the initials of the author; the date and time of the dictation, the transcriptionist’s initials. At the direction of the MTF, the Contractor shall insert additional information, such as signature blocks, on certain types of reports.

5.8. Destination of transmitted documents into system: Contractor is required to transmit documents using the “WORD” program for any correction that is needed by the dictating provider. The final document will be in PDF format after final review and provider signature completed.

6. Quality Control Program: The contractor is responsible for the quality of services under the terms of this contract. To ensure that requirements are met, the contractor shall implement an effective, economical quality control program to identify, prevent, and insure non-recurrence of effective services and satisfactory performance of objectives listed in the SDS are achieved. The contractor shall provide a copy of its quality control procedures to the government within 30 days of contract start date.

II. SERVICE DELIVERY SUMMARY

The service requirements are summarized into performance objectives that relate directly to mission essential items. The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. The thresholds are critical to mission success and the percentages shown indicate the minimum for acceptable (satisfactory) performance.

Performance

Objective

Threshold

98 % Compliance

98 % Compliance

100% Compliance

Properly maintains and disposes of records

100%

Compliance

III. Government - Furnished Property and Services: None

iv. GENERAL INFORMATION

7. Contractor Point of Contact:

a. The Contractor shall provide a point of contact (POC) and alternate(s) that shall be responsible for ensuring that the contract services are provided satisfactorily. The POC and alternate(s) shall be designated in writing to the contracting officer within five days of contract award date. The contractor POC and alternate(s) shall have full authority to act for the Contractor on all contract matters relating to daily operation of this contract. The POC or alternate(s) shall be available to discuss any problems that may arise. The POC and alternate(s) must be able to read, write, speak, and understand English.

b. Should a dictation problem arise that requires action from the FRED (Functional Requirements Evaluator Designee), the contractor POC or alternate(s) shall be responsible for ensuring that dictation and or transcription report problems are flagged or identified if unable to flag. A brief explanation of the nature of the problem shall be provided daily via email to the FRED. The flagged/identified report explanation shall include at a minimum, the RTAS reference number, patient's name and last 4 digits of the social security number, CHCS examination number, name of the dictating physician and the nature of the problem.

8. Contractor Employees:

a. The Contractor shall not employ any person who is an employee of the U.S. Government if employing that person would create a conflict of interest. Additionally, the Contractor shall not employ any person who is an employee of the Department of the Air Force, either military or civilian, unless such person seeks and receives approval according to DOD 5500.7-R, the Joint Ethics Regulation (JER).

b. The Contractor is cautioned that off-duty active military personnel hired under this contract may be subject to permanent change of station, exchange in duty hours, or deployment. Military Reservists and National Guard members may be subject to recall to active duty. The abrupt absences of these personnel could adversely affect the Contractor’s ability to perform, however, their absence at any time shall not constitute an excuse for nonperformance under this contract.

9. The Contractor shall comply with the Privacy Act of 1974 (the Act) and AFI 33-322, the Air Force Privacy Act Program and the agency rules and regulations issued under the Act in the design, development operation of any system of records. Operation of a system means performance of any of the activities associated with maintaining the system of records, including the collection, use and dissemination of personal information. Systems of Records on individuals are defined as a group of any records under the control of an agency from which information is retrieved by the name of the individual or by some identifying number, symbol or other identification unique to the individual.

a. All records generated during the performance of the contract are considered Government records and shall be turned over to the Government upon termination of the contract.

b. Records are considered to be all books, papers, maps, photographs, machine-readable materials or other documentary materials, regardless of physical form or characteristics, made or received by any agency of the Government under federal laws, or in connection with the transactions of public business, and preserved or appropriate for preservation by any agency, or its legitimate successor, as evidence of the organization, functions, policies, decisions, procedures, operations or other activities of the Government or because of the informational value of data in them. This includes all electronic records, which must meet the requirements of DODSTD50152.

10. FOR OFFICIAL USE ONLY (FOUO). The Contractor shall create and Maintain FOUO material IAW DoD 5400-7,R, DoD Freedom of Information Act Program, Chapter 4, AFI 33-129, Transmission of Information Via the Internet, paragraphs 7.4, 8.23, 16 and 17; and AFI 33-201, Communications Security (COMSEC), Table 1. Mark all documents meeting the requirements identified in DoD Regulation 5400.7/Air Force Supplement, paragraphs C3.2.1.2 thru C3.2.1.9 as “For Official Use Only” IAW instructions identified in paragraph C4.2.1. Safeguard all sensitive data IAW DoD Regulation 5400.7/Air Force Supplement, paragraph C4.4. When documents containing FOUO material are authorized for destruction, shred the records so that the pieces cannot be reconstructed. Degauss or overwrite magnetic tapes or other magnetic media. Records Disposition shall be IAW with the Records Disposition Schedule available on the WebRIMSs website at https://webrims.amc.af.mil/login.cfm.

11. Patient Lists: Patient lists, no matter how developed, shall be treated as privileged information. Add the following to the bottom of all patient lists: “FOR OFFICIAL USE ONLY.” This document contains information exempt from mandatory disclosure under the Freedom of Information Act (FOIA)., Title 5 U.S.C 552(b)(2) High and (b)(6) apply.” Lists and/or names of patients shall not be disclosed or revealed in any way for any use outside the MTF without prior written permission by the Chief of Hospital Services.

12. Privacy Act Program: The Contractor shall create and maintain Privacy Act data IAW

AFI33-129, Transmission of Information Via the Internet, paragraphs 7.4, 8.2.3, 16 and 17 and supplements; AFI 33-201, Communications security (COMSEC), Table 1; AFI 33-332, Air Force Privacy Act Program, paragraphs 1.4.7, 1.4.8, 3.3.3, Chapter 7, Chapter 9, Chapter 10 and supplements and Privacy Act systems of records notice(s), which are posted on the internet at (http://www.defenselink.mil/privacy/notices/usaf). The Contractor shall not create or maintain a Privacy Act system of records prior to public notice. If the Contractor receives a Privacy Act request, the Contractor shall be responsible for searching for the records and providing those records to the Government official who, as authorized official, will make the decision on releasing Government records.

13. DoD Freedom of Information Act (FOIA) Program: If the Contractor receives a FOIA request the Contractor shall immediately hand-carry it to the base FOIA manager for processing. The FOIA manager will task a Government official. When tasked, the Contractor shall be responsible for searching for the records and providing those records to a Government official who, as the authorized official, will make the decision on releasing Government records.

14. Functional Requests: A written request for DoD records that does not cite either the FOIA or Privacy Act may be received from any person (including a member of the public), or organization, or a business. The Contractor shall be responsible for searching for the records and providing those records to a Government official who, as the authorized official, will make the decision on releasing Government records.

15. AFI33-332, The Air Force Privacy and Civil Liberties Program

15.1.3. PII accessed or handled by contractors. Contractors who are required to access or handle PII on behalf of the Air Force, must follow this Instruction. Organizations who have contractors accessing and handling PII must coordinate with contracting officials to ensure the contract contains the proper Privacy Act clauses: 52.224-1, Privacy Act Notification; and 52.224-2, Privacy Act as required by the Federal Acquisition Regulation (FAR) (see FAR website at: http://www.acquisition.gov/far/).

15.1.3.1. Contracts must be reviewed annually by the Resource Advisor to ensure compliance with this Instruction.

15.1.3.2. Disclosure of PII to contractors for use in the performance of an Air Force contract is considered an official use disclosure within the agency under exception (b)(1) of the Privacy Act.

15.1.3.3. Commanders/Directors shall ensure training and communication related to privacy and security is job specific and commensurate with an individual's responsibilities. Such training shall be a prerequisite before an employee, military member, or contractor is permitted to access DoD information systems that contain Privacy Act material. Such training is mandatory for AF military personnel, employees and managers, and shall include contractors and business partners. Training must be provided and documented by the Privacy Manager/Monitor.

16. PRIVACY ACT NOTIFICATION (APR 1984)

The Contractor will be required to design, develop, or operate a system of records on individuals, to accomplish an agency function subject to the Privacy Act of 1974, Public Law 93-579, December 31, 1974 (5 U.S.C. 552a) and applicable agency regulations. Violation of the Act may involve the imposition of criminal penalties.

16.1 52.224-2 Privacy Act. As prescribed in 24.104, insert the following clause in solicitations and contracts, when the design, development, or operation of a system of records on individuals is required to accomplish an agency function:

PRIVACY ACT (APR 1984)

(a) The Contractor agrees to—

(1) Comply with the Privacy Act of 1974 (the Act) and the agency rules and regulations issued under the Act in the design, development, or operation of any system of records on individuals to accomplish an agency function when the contract specifically identifies—

(i) The systems of records; and

(ii) The design, development, or operation work that the contractor is to perform;

(2) Include the Privacy Act notification contained in this contract in every solicitation and resulting subcontract and in every subcontract awarded without a solicitation, when the work statement in the proposed subcontract requires the design, development, or operation of a system of records on individuals that is subject to the Act; and

(3) Include this clause, including this subparagraph (3), in all subcontracts awarded under this contract which requires the design, development, or operation of such a system of records.

(b) In the event of violations of the Act, a civil action may be brought against the agency involved when the violation concerns the design, development, or operation of a system of records on individuals to accomplish an agency function, and criminal penalties may be imposed upon the officers or employees of the agency when the violation concerns the operation of a system of records on individuals to accomplish an agency function. For purposes of the Act, when the contract is for the operation of a system of records on individuals to accomplish an agency function, the Contractor and any employee of the Contractor is considered to be an employee of the agency.

(c)(1) Operation of a system of records, as used in this clause, means performance of any of the activities associated with maintaining the system of records, including the collection, use, and dissemination of records.

(2) Record, as used in this clause, means any item, collection, or grouping of information about an individual that is maintained by an agency, including, but not limited to, education, financial transactions, medical history, and criminal or employment history and that contains the person's name, or the identifying number, symbol, or other identifying particular assigned to the individual, such as a fingerprint or voiceprint or a photograph.

(3) System of records on individuals, as used in this clause means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifying particular assigned to the individual.

17. RECORDS, FILES, DOCUMENTS, DATA AND WORK PAPERS

All records, files, documents, data and work papers provided by the Government remain Government property. The FRED will provide guidance to the contractor who shall maintain and dispose of these records, files and documents in accordance with Air Fore Manual 33-363 and IAW applicable HIPAA requirements as stated in the HIPAA clause. Contractor will comply with all AFRIMS requirements for safe keeping, handling, release and disposal of any of the above information. These AFRIMS requirements shall include, but are not limited to: limiting access to government data, tracking information for origin to disposal, removal of personal identifiers and thoroughly destroying information when work is completed in accordance with Federal Law and DoD Regulations.

APPENDIX A

WORKLOAD ESTIMATES

(Historic and Projected)

Number of Documents by Type

Document Types

NS

Narrative Summary

TNS

Transfer Summary

CON

Consultation

DS

Death Summary

MEB

Medical Evaluation Board Summary

TDRL

Temporary Duty Retirement List Summary

PN

Radiation Oncology Progress

TS

Radiation Oncology Treatment Summary

HP

History/Physical Summary

OR

Operation Report

Lines Transcribed by Fiscal Year

Fiscal Year 2013 Totals: 292, 302 Fiscal Year 2014 Totals: 113, 112 (Oct 2013- Jan 2014 data only) Fiscal Year 2015 Totals: 253,142 Fiscal Year 2016 Totals: 192,535 Fiscal Year 2017 Totals: 151,591

APPENDIX B

TURNAROUND TIME (TAT)

FOR DAVID GRANT USAF MEDICAL CENTER

October 2014 – September 2018

Operative Reports

24 hours

Narrative Summaries

Consultations

Death Summaries

MEB/TDRL Summaries

Radiation Oncology Progress Notes

Radiation Oncology Treatment Summaries

History and Physicals

Miscellaneous

All STAT dictation

4 hours

NOTE: TAT is calculated on a 24-hour basis, including weekends and holidays.

APPENDIX C

STANDARDIZED ABBREVIATIONS, ACRONYMS AND SYMBOLS

Must be in compliance with MDGI 44-96, Standardized Abbreviations, Acronyms and Symbols, and Appendix D.

APPENDIX D

DGMC DO NOT USE ABBREVIATIONS

Effective 1 April 2013

(for unit)

(for international unit)

3.

Q.D. QD, q.d., qd (daily)

Write “daily” and “every other day”

5.

Trailing zero

(X.0 mg),

*Never use terminal zeros for doses expressed in whole numbers.

*Always use zero before a decimal when the dose is less than a whole unit.

7.

8.

9.

MS

MSO4

MgSO4 Confused for one another.

Can mean morphine sulfate or magnesium sulfate Write

“morphine sulfate” or

“magnesium sulfate”

administration: intratumor, intratympanic, inhalation therapy, & intratracheal Write “intrathecal”

APPENDIX E

Template Samples

TISSUE SAMPLE TEMPLATE

PRIVATE

MEDICAL RECORD

RADIATION THERAPY SUMMARY

PRIVATE

Diagnosis:

Sex

Race

Age

Date of Consultation

NARRATIVE SUMMARY

1. DIAGNOSIS:

2.

STAGE:

3, 4, and 5:

BRIEF CLINICAL HISTORY:

6. PLAN OF TREATMENT:

7.

DATES OF TREATMENT:

8. TUMOR DOSE SUMMARY:

9. RESPONSE:

10. TOLERANCE:

11. DISPOSITION:

Cc:

Physician Information

Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

(SF 516)

NAME:

CONSULTATION SHEET

(SF 513)

(SF 502)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

(SF 503)

UNIT

DATE TYPED

5-275-102

MEDICAL RECORD REPORT

Computer Generated Form

OPTIONAL FORMS 275 (12-77)

Prescribed by GSA and 1CMR

FIRMR (41 CFR) 201-45.505

DEATH SUMMARY TEMPLATE

PRIVATE

MEDICAL RECORD

Date of Death

Dictated by:

DEATH SUMMARYPRIVATE

SERVICE:

STAFF:

CAUSE OF DEATH:

Primary Admission Diagnosis:

Admission Diagnosis #2-5

HOSPITAL COURSE:

History of Present Illness:

Hospital Course:

Procedure Performed:

Final Diagnosis:

Additional Contributing Diagnosis:

Contributing Diagnosis #2-5

Autopsy: Yes No

Staff Physician of Record:

Physician Information Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE TYPED

5-275-102

HISTORY AND PHYSICAL TEMPLATE

PRIVATE

MEDICAL RECORD

Date of Pre-op

Date of Operation

Dictated by:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

ALLERGIES:

MEDICINES:

SOCIAL HISTORY:

PHYSICAL EXAMINATION:

GENERAL:

IMAGING:

IMPRESSION:

PLAN:

Physician Information Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

DISCHARGE SUMMARY TEMPLATE

PRIVATE

MEDICAL RECORD

Date of Admission

Date of Discharge

Dictated by:

DISCHARGE SUMMARY:

STAFF PHYSICIAN:

RESIDENT:

INTERN:

ADMISSION DIAGNOSES:

DISCHARGE DIAGNOSES:

DISCHARGE MEDICATIONS:

DISCHARGE DISPOSITION:

PROCEDURES/CONSULTS:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

ALLERGIES:

MEDICATIONS

FAMILY HISTORY:

SOCIAL HISTORY:

OTHER REVIEW OF SYSTEMS:

ADMISSION PHYSICAL EXAMINATION:

STUDIES:

LABORATORY:

HOSPITAL COURSE:

DISCHARGE PHYSICAL EXAMINATION:

DISCHARGE LABORATORY:

DISCHARGE INSTRUCTIONS AND FOLLOW-UP:

CODE STATUS:

Cc:

Physician Information

Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

MEDICAL EVALUATION BOARD TEMPLATE

PRIVATE

MEDICAL RECORD

Dictated by:

MEDICAL EVALUATION BOARDPRIVATE

PATIENT DEMOGRAPHICS:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PERTINENT PAST MEDICAL HISTORY:

PERTINENT PAST SURGICAL HISTORY

PERTINENT FAMILY HISTORY:

CURRENT MEDICATIONS:

HPI-POTENTIALLY UNFITTING DIAGNOS(ES):

TARGETED PHYSICAL EXAM:

ANCILLARY STUDY SUMMARY:

PERTINENT LABS:

PERTINENT RADS:

PERTINENT OTHER:

CONSULTATION SUMMARY:

CURRENT PROFILE RESTRICTIONS:

OCCUPATIONAL IMPACT:

PROGNOSIS:

Physician Information

Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

PRIVATE

MEDICAL RECORD

Date of Admission

Date of Discharge

Dictated by:

NARRATIVE SUMMARY TEMPLATE

ADMITTING DIAGNOSES:

ATTENDING PHYSICIAN:

RESIDENT:

INTERN:

HISTORY OF PRESENT ILLNESS:

PERTINENT LABORATORY/RADIOLOGY:

HOSPITAL COURSE:

DISCHARGE INSTRUCTIONS:

CONDITION ON DISCHARGE:

DISCHARGE MEDICATIONS:

FOLLOW-UP:

Cc:

Physician Information

Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

Computer Generated From

OPERATION REPORT TEMPLATE

PRIVATE

MEDICAL RECORD

OPERATION REPORT

PRIVATE

Preoperative Diagnosis:

Circulating Nurse:

See AF Form 1864 Instrument Nurse:

See AF Form 1864 See AF Form 1864 for surgery beginning and ending time.

PRIVATE

Operative Diagnosis:

Drains: (Kind & No.)

Sponge Count Verified

Correct

Material Forwarded to Laboratory for Examination:

Operation Performed:

PRIVATE

Description of Operation:

Major

Minor

Date of Operation:

Staff:

EBL:

FLUIDS:

INDICATIONS:

SPECIMENS:

IMPLANT OR DEVICE:

PROCEDURE IN DETAIL

Physician Information Doc#

Job#

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

PROGRESS NOTE TEMPLATE

RADIATION ONCOLOGY PROGRESS NOTE

IDENTIFICATION:

SUBJECTIVE:

PHYSICAL EXAMINATION:

RADIOLOGIC DATA:

ASSESSMENT:

PLAN:

Physician Information

Doc:

Job:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

TRANSFER SUMMARY TEMPLATE

PRIVATE

MEDICAL RECORD

Date of Admission

Date of Transfer

Dictated by:

Attending physician:

Resident:

Interns:

PROCEDURES/STUDIES:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PHYSICAL EXAMINATION:

DIAGNOSTIC STUDIES:

HOSPITAL COURSE:

CONDITION ON DISCHARGE:

DISCHARGE MEDICATIONS:

DISCHARGE INSTRUCTIONS:

Physician Information

Doc#:

J#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

CONSULTATION TEMPLATE

PRIVATE

MEDICAL RECORD

CONSULTATION SHEET

Reason for Request:

Provisional Diagnosis:

Place of Consultation:

HISTORY OF PRESENT ILLNESS:

PAST HISTORY:

PAST MEDICAL AND SURGICAL HISTORY:

MEDICATIONS:

ALLERGIES:

SOCIAL HISTORY/HABITS:

REVIEW OF SYSTEMS:

PHYSICAL EXAMINATION:

IMPRESSION:

PLAN:

Cc:

Physician Information

Doc.#:

Job#:

PRIVATE

HISTORY & PHYSICAL EXAMINATION

(SF 504, SF 505 & SF 506)

NAME:

(SF 513)

REGISTER NO.

SSN

DAVID GRANT USAF MEDICAL CENTER TRAVIS AFB, CA 94535-5300

UNIT

DATE DICT

DATE TYPED

5-275-102

APPENDIX F

REQUIRED DAILY REPORT FORMAT

Completed Medical Transcription Report

Period (first day of the month through the last day of the month) And Year

DAILY LINE ACCOUNTING REPORT

Type Job # # Lines Job # # Lines

History and Physicals

Operative Reports

Discharge Summary

Consults

Radiology Reports

Medical Boards

Progress Notes

Clinic Notes

Narrative Summaries

Other:

Totals

DAILY NOTIFICATION REPORT

APPENDIX G

Applicable Instructions Publications and forms are available electronically through the internet. For example: http://www.e-publishing.af.mil/ is the Air Force’s e-publishing site and one way to obtain Air Force Instructions. DoD Directives can be found at http://www.esd.whs.mil/DD/. Regulations are followed by a “-R” (e.g., DoD 5200.-R) and be located on a website by clicking on “publications” instead of “directives”. 60th Medical Group Instructions (60 MDGIs) can be located on the MTF website and can be provided to the contractor upon request.

Publications Code:

AFI--Air Force Instruction

AMC--Air Mobility Command

DoDI--DoD Instruction

MDGI--60th Medical Group Instruction

DEPARTMENT OF DEFENSE (DoD) REGULATIONS/MANUALS INSTRUCTIONS/DIRECTIVES

PUB NO

Title of Directive DoDI 5400.7-R

DoD Freedom of Information Act

DoDI 5500.7-R

Joint Ethics Regulation (JER)

DoDR 6025.18-R

Health Information Privacy Regulation

AFI 33-332 Privacy Act Program

AMC Sup 1 Transmission of Information Via the Internet

AFI 33-332 Air Force Privacy and Civil Liberties Program

AFI 41-210 Tricare Operations and Patient Administration Functions

OTHER DIRECTIVES:

MDGI 44-96

Standardized Abbreviations, Acronyms and Symbols

PrivacyAct Systems of Records Notice(s) at http://www.defenselink.mil/privacy/notices/usaf

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