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COMPLETING REQUIRED FORMS

LEARNING OBJECTIVE: Select the appropriate form(s) used for physical examinations and recall how each form should be completed.

While there are several forms used to record physicals, the scope and purpose of the physical dictates which form or forms should be used. For example, the preplacement and annual physical evaluation of food service personnel or personnel exposed to hazardous materials can, in most cases, be adequately documented on an SF 600. This section discusses the most commonly used physical examina- tion forms.

REPORT OF MEDICAL EXAMINATION, SF 88

The SF 88, Report of Medical Examination, is the principal document for recording a complete physical

examination (figs. 11-1 and 11-2). The SF 88 is, like most medical documentation, a legal document. Entries on the form must be legible. If you make a typographical or clerical error, correct the entry by drawing a single line through the erroneous entry, initialing above the error, and making the corrected entry in the same block. If space is not available in that block, make the corrected entry in block 42 (identifying the erroneous entry by number). Chapter 16 of the MANMED provides specific details on information for each block to complete this form properly.

Stamps are used routinely by many naval medical facilities to incorporate routine information or data onto medical documents, as illustrated in blocks 50 and 73 of figures 11-1 and 11-2. The use of stamps must, however, be in accordance with physical examination directives and the MANMED.

REPORT OF MEDICAL HISTORY, SF 93
The purpose of Standard Form (SF) 93, Report of Medical History, is to provide a complete personal medical history and to serve as a source of information that supplements information reported on the SF 88. The SF 93 provides a current, concise, and comprehensive record of a service member's personal medical history before entering the service and any subsequent changes in the member's medical status.

After the military entrance examination, any subsequent medical examinations that require the use of the SF 88 will also require an SF 93 to be completed. Any medical information entered by patients on the SF 93 is made only to document changes in medical history since their last physical examination. If no changes have occurred since the previous SF 93 was generated, the examiner should enter "no significant interval history" in block 25.

When you prepare the SF 93, complete items 1 through 7 in the same manner as you did the SF 88 (fig. 11-3). This information can be handwritten or typed. Inform examinees that they are responsible for completing items 8 through 25 (figs. 11-3 and 11-4). Item 8 should contain a handwritten statement from examinees regarding their present state of health and any medications they may be taking. Items 9 through 24 are checked either "yes," "no," or "don't know" by the examinees. Assist examinees by explaining unfamiliar medical terminology that appears on these items. Helping them complete the form will ensure an accurate accounting of the member's medical history. Keep in mind that the SF 93 is information of

Figure 11-1.-Example of completed front side of SF 88.



Figure 11-2.-Example of completed back side of SF 88.



Figure 11-3.-Example of front side of SF 93.



Figure 11-4.-Example of back side of SF 93.

significant or chronic disorders instead of one-time events of minor illnesses or disorders.

An essential part of a complete physical examination is the review of patient's medical history. The medical examiner is responsible for reviewing items 9 through 24 of the SF 93. After reviewing these items, the medical examiner uses item 25 to elaborate on all "yes" responses (fig. 11-4). Examiners document conditions considered disqualifying as "CD" and those considered not disqualifying as "NCD." Examiner's signature and identification information should be documented at the bottom of the back side of the SF 93.



 


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