as involvement in the Asbestos Program, the Hearing
Conservation Program, or exposure to lead. Include
also the following laboratory tests: blood type, G6PD,
and sickle trait.
CHRONOLOGICAL RECORD OF
MEDICAL CARE (SF 600)
The Chronological Record of Medical Care, SF 600,
provides a current, concise, and comprehensive record of
a members military medical history (fig. 12-4, view A
and B). Use the SF 600 for all outpatient care and file in
the HREC. Record all visits, including those that result in
referrals to other MTFs, on the SF 600. Each person
making an entry on the form must sign the entry and
include his identification information (full name, grade
or rate, profession [e.g., MC, NC, etc.], and SSN), either
hand printed, typed, or stamped.
Properly maintained, the SF 600 facilitates the
evaluation of a patients physical condition and
reduces correspondence necessary to obtain medical
records. Appropriate use of the form also eliminates
unnecessary repetition of expensive diagnostic
procedures and serves as an invaluable permanent
record of medical evaluations and treatments.
Completing the SF 600
Entries made on the SF 600 can be typewritten
when practical.
However, entries normally are
handwritten with black or blue-black ink pens. When
initiating an SF 600, patient identification data should
be completed.
Also, type or stamp the date
(DD-MMM-YY) and the name and address of the
activity responsible for the entry.
Use both sides of each SF 600. Preparation of a
new SF 600 is not necessary each time the person is
seen in a different MTF. If only a few entries are
recorded on the SF 600 at the time of a move, stamp the
designation and location of the receiving MTF below
the last entry and use the rest of the page to record
subsequent visits. If the back of the SF 600 is not used,
then the back needs to be crossed out and the words
This side not used, printed in the middle of the form.
SF 600s are continuous and include the following
information: complaints, duration of illness or injury,
physical findings, clinical course, results of laboratory
or other special examinations, treatment (including
operations), physical fitness at the time of disposition,
and disposition.
The subjective complaint,
observation, assessment, and plan (SOAP) format may
be used for entries so long as the required information
in table 12-3 is included.
Enter the following information indicated on table
12-3 on the patients SF 600.
Record each visit and the complaint described,
even if a member is returned to duty without treatment.
Also, document if a patient leaves before being seen.
Other SF 600 Entries
Other SF 600 entries include the following:
Imminent hospitalization
Special procedures and therapy
Sick call visit
12-13
ITEM
REMARKS
Date
A complete date must be
included with every entry in the
HREC. When an undated page is
misfiled, it is difficult to replace
in proper sequence. Use the
three-letter abbreviation for the
month on all dates (e.g., 27 Apr
96).
MTF name
Name of hospital, clinic, or ship
Clinical
department or
service
(e.g., Military Sick Call,
Orthopedic Department.,
etc.)
Chief complaint or
purpose of visit
(e.g., headache, PRT
screening, etc.)
Objective findings
Diagnosis or
medical
impression
Studies ordered
and results
(e.g., laboratory, X-ray, etc.)
Therapies
administered
Patient
disposition,
recommendations,
and patient
instructions
(e.g., SIQ for 24 hours, referral
to specialty clinic, etc.)
Healthcare
providers name
and signature
Include the providers grade or
rate, profession (e.g., MC, NC),
and SSN
Table 12-3.Required Information on an SF 600