How to Fill Out DA Form 2984

DA Form 2984 at a glance

What it is: DA Form 2984 is the Very Seriously Ill/Seriously Ill/Special Category Patient Report.

Who signs: The MEDICAL OFFICER signs in box 11 and the PATIENT ADMINISTRATOR OR ADMINISTRATIVE OFFICER OF THE DAY signs in box 21.

A filled-in DA Form 2984 example: a seriously ill patient is reported

DA Form 2984 example filled out, example: a seriously ill patient is reported — A patient administrator reports a seriously ill patient on DA Form 2984. The medical officer expects recovery, so the example marks SERIOUSLY ILL and EXPECTED on the report. The picture shows the whole page, and every value in it is made up. Nobody asks for a change of status, so Change of status stays empty. The patient is seriously ill, so EXPECTED LENGTH OF HOSPITALIZATION and SPECIAL CATEGORY stay empty. Remarks is left blank because the report needs no remarks. 18. OTHER (Specify) is left blank because nobody else is notified. The fillable form has no field for the method of notification, so the example leaves it for you to initial by hand after printing. The patient is the sponsor, so the entry has no family member prefix. The person, the information office, the Red Cross, the chaplain and the unit commander are all notified on the same day.

How to fill out DA Form 2984, box by box

To: patient administrator or administrative officer of the day

Mark PATIENT ADMINISTRATOR or ADMINISTRATIVE OFFICER OF THE DAY after TO.

1. Date, 2. Hour, 3. Religion of patient, 4. Ward, 5. Relationship and 6. Name and address

Enter the DATE in box 1 and the HOUR in box 2.

Enter the RELIGION OF PATIENT in box 3 and the WARD in box 4.

Enter the RELATIONSHIP in box 5 and the NAME AND ADDRESS in box 6.

7. Brief diagnosis

In box 7, enter the BRIEF DIAGNOSIS and use lay terminology.

8. Status of patient

In box 8, STATUS OF PATIENT, mark VERY SERIOUSLY ILL, then PROGNOSIS: RECOVERY IS - NOT EXPECTED or QUESTIONABLE.

Mark SERIOUSLY ILL, then PROGNOSIS: RECOVERY IS - QUESTIONABLE or EXPECTED.

Mark NON SERIOUSLY ILL, then enter the EXPECTED LENGTH OF HOSPITALIZATION in DAYS.

For SPECIAL CATEGORY, specify the category.

Change of status

CHANGE OF STATUS lists SI TO VSI, VSI TO SI, TRANSFERRED, RECOVERED, DIED and ADDITIONAL SPECIAL CATEGORY (Specify in remarks).

9. Remarks, 10. Typed or printed name of medical officer and 11. Signature

Write the REMARKS in box 9.

For ACTION TAKEN BY MEDICAL OFFICER, enter the TYPED OR PRINTED NAME OF MEDICAL OFFICER in box 10 and sign the SIGNATURE in box 11.

Action taken by patient administrator or administrative officer of the day

For ACTION TAKEN BY PATIENT ADMINISTRATOR OR ADMINISTRATIVE OFFICER OF THE DAY, enter the METHOD OF NOTIFICATION (Initial one): TELEPHONE, TELEGRAM, LETTER or IN PERSON.

For 12. REPORT RECEIVED, enter the ACTION, DATE and HOUR.

Under NOTIFIED, enter the ACTION, DATE and HOUR for 13. PERSON (Same as Item 6), 14. INFORMATION OFFICE, 15. RED CROSS, 16. CHAPLAIN, 17. UNIT COMMANDER and 18. OTHER (Specify).

Patient's identification, 20. Name and 21. Signature

In PATIENT'S IDENTIFICATION, for typed or written entries give: Name - last, first, middle; grade; family member prefix.

Enter the TYPED OR PRINTED NAME OF PATIENT ADMINISTRATOR OR ADMINISTRATIVE OFFICER OF THE DAY in box 20 and sign the SIGNATURE in box 21.

More rules for DA Form 2984

For use of this form, see AR 40-400; the proponent agency is OTSG.

Sources

[1] DA Form 2984 (APR 2009), Very Seriously Ill/Seriously Ill/Special Category Patient Report, U.S. Army (the Official source link on this page).

DA Form 2984 PDF Details