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Automation of Medical Standard Form 504

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Information about this document as published in the Federal Register.

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Start Preamble


Office of Communications, GSA.


Guideline on Automating Medical Standard Forms.


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 proposes 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 required 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 504

ItemPlacement *
History—Part 1 (Title)Top of form.
Standard Form 504 (Rev. 8/2001) (Form ID)Bottom right corner of form.
Start Printed Page 63430
Data Entry Fields:
Nature and Duration of Complaints (Include circumstances of admission)
  History of Present Illnesses
  Relationship to Sponsor
  Sponsor's Name—Last
  Sponsor's Name—First
  Sponsor's Name—MI
  Sponsor's ID Number (SSN or Other)
  Hospital or Medical Facility
  Records Maintained At
  Register No.
  Ward No.
Patient Information (Text)Above below listed items.
  Last Name
  First Name
  Middle Name
  ID No. or SSN
  Date of Birth
* If no specific placement, data element may be in any order.
Start Further Info


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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Dated: February 12, 2002.

Katherine Ciacco Palatianos,

Chairperson, Interagency Committee on Medical Records.

End Signature End Further Info End Preamble

[FR Doc. 02-25919 Filed 10-10-02; 8:45 am]