Da Form 3647 PDF Details

The Da 3647 form, titled "Inpatient Treatment Record Cover Sheet," serves a crucial function in documenting the medical care and services provided to individuals admitted to medical facilities. This comprehensive form, governed by the regulations outlined in AR 40-400 and managed by the OTSG (Office of The Surgeon General), meticulously records various aspects of an inpatient's treatment journey. Essential details such as the patient's register number, name, grade, and demographic information, including sex, age, race, and religion, are captured at the outset. The form also delves into more specific data like length of service, previous admissions, and the patient’s social security number, providing a holistic view of the patient's military background and identification. Treatment-related information, including the type of case, source of admission, and diagnostic details alongside the surgical or special procedures undertaken, are precisely noted. Administrative data, key dates related to the admission and disposition, emergency contact information, and the overall duration of hospital stay, both at the facility and cumulatively across all facilities, are also included. The document concludes with a section for the signatures of the attending medical officer and the PAD or medical records officer, ensuring the accuracy and official validation of the information provided. The DA Form 3647 thus stands as an essential record, facilitating thorough communication and coordination among medical personnel for the optimal care of the patient.

QuestionAnswer
Form NameDa Form 3647
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 3647 hhs, form 3647, da treatment sheet, inpatient cover sheet

Form Preview Example

INPATIENT TREATMENT RECORD COVER SHEET

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

1.

REGISTER NUMBER

 

 

2.

NAME (Last, First, MI)

 

 

 

 

 

 

 

3.

GRADE

ADMISSION REMARKS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

SEX

5.

AGE

6.

RACE

7.

RELIGION

8.

LENGTH OF SVC

9.

ETS

 

 

10.

PREVIOUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMISSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

FMP

 

 

12.

SSN

 

 

13.

ORGANIZATION

 

 

 

 

14.

WARD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

FLYING

 

16.

RATING/

17.

DEPT./

18.

BRANCH/CORPS

19.

UIC/ZIP

 

 

20.

TYPE CASE

 

 

STATUS

 

 

DSG

 

 

BEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION

 

 

 

 

22.

HOURS OF

23.

CLINIC SERVICE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMISSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

 

 

25.

TYPE DISPOSITION

26.

DATE OF DISPOSITION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27a.

ADDRESS OF EMERGENCY ADDRESSEE (Include ZIP Code)

 

 

27b.

TELEPHONE NO.

28.

DATE OF THIS

ADMITTING OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMISSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

 

 

 

 

 

 

30.

DATE OF INTIAL

32. UNITS OF WHOLE BLOOD/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADMISSION

 

 

 

COMPONENT TRANSFUSED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31.

SELECTED ADMINISTRATIVE DATA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if Continued on Reverse

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33.

CAUSE OF INJURY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34.

DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

Total Days This Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

ABSENT SICK DAYS

b.

OTHER DAYS

c.

CONV. LV/COOP

d.

SUPPLEMENTAL

e.

BED DAYS

f.

TOTAL SICK DAYS

 

 

 

 

 

CARE DAYS

 

CARE DAYS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

36.

Total Days All Facilites

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.

ABSENT SICK DAYS

b.

OTHER DAYS

c.

CONV. LV/COOP

d.

SUPPLEMENTAL

e.

BED DAYS

f.

TOTAL SICK DAYS

 

 

 

 

 

CARE DAYS

 

CARE DAYS

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF ATTENDING MEDICAL OFFICER

 

 

SIGNATURE OF PAD OR MEDICAL RECORDS OFFICER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DA FORM 3647, MAY 1979

EDITION OF 1 AUG 76 IS OBSOLETE

APD LC v1.11ES

APD LC v1.11ES

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