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Interagency Committee for Medical Records (ICMR); Automation of Medical Standard Form 519A

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Office of Communications, GSA.


Guideline on Automating Medical Standard Forms.

Background: The Interagency Committee on Medical Records (ICMR) is aware of numerous activities using computer-generated medical forms, many of which are not mirror-like images of the genuine paper Standard/Optional Form. With GSA's approval the ICMR eliminated the requirement that every electronic version of a medical Standard/Optional form be reviewed and granted an exception. The committee proposed to set required fields standards and that activities developing computer-generated versions adhere to the required fields but not necessarily to the image. The ICMR plans to review medical Standard/Optional forms which are commonly used and/or commonly computer-generated. We will identify those fields which are required, those (if any) which are optional, and the required format (if necessary). Activities may not add or delete data elements that would change the meaning of the form. This would require written approval from the ICMR. Using the process by which overprints are approved for paper Standard/Optional forms, activities may add other data entry elements to those required by the committee. With this decision, activities at the local or headquarters level should be able to develop electronic versions which meet the committee's requirements. This guideline controls the “image” or required fields but not the actual data entered into the field.


With GSA's approval, the Interagency Committee of Medical Records (ICMR) eliminated the requirement that every electronic version of a medical Standard/Optional form be reviewed and granted an exception. The following fields must appear on the electronic version of the following form:

Electronic Elements for SF 519A

ItemPlacement 1
Radiologic consultation request/reportTop of form.
Standard Form 519A (Rev. 8/1983)(Form ID)Bottom right corner of form.
1-Medical RecordBottom left corner of form.
2-PhysicianBottom left corner of form.
3-RadiologyBottom left corner of form.
Data Entry Fields:
Patient information (Text)Above below listed items.
Last name
First name
Middle name
Medical facility
SSN (Sponsor)
Register No.
Examination requested (Use SF 519B for multiple exams)
Requested by
Telephone number
Location of medical records
Film number
Date requested
Pregnant—Yes (Checkbox)
Pregnant—No (No)
Specific reason(s) for Request (Complaints and findings)
Date of examination (Month, day, year)
Date of report (Month, day, year)
Date of transcription (Month, day, year)
Radiologic report
Location of radiologic facility
1 If no specific placement, data element may be in any order.
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CDR Katherine Ciacco Palatianos, Indian Health Service, Department of Health and Human Services, 5600 Fishers Lane, Room 6A-55, Rockville, MD 20857 or E-Mail at

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Effective February 25, 2002.

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Dated: February 12, 2002.

CDR Katherine Ciacco Palatianos,

Chairperson, Interagency Committee on Medical Records.

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[FR Doc. 02-4452 Filed 2-22-02; 8:45 am]