Da Form 5181 R PDF Details

The DA Form 5181 R, known as the Screening Note of Acute Medical Care, plays a crucial role in the documentation and management of medical care within the military context. Mandated by AR 40-66 and developed under the guidance of the Office of The Surgeon General, this form meticulously records various essential aspects of a patient's visit for acute medical care, emphasizing the importance of an accurate and thorough medical documentation process. It captures a series of critical data points—from the time the patient leaves their unit to the final disposition of their visit, including chief complaints, vital signs, residence, and allergy information. This form is not only instrumental in documenting first-time visits but also in tracking follow-up care when necessary, indicating whether a return visit was initiated by the care provider. Furthermore, it encompasses patient identification details and concludes with the final disposition of the patient, which could range from physician consultation to self-care protocols or hospital clinic referrals. The DA Form 5181 R serves as an alternative to the SF 600 (Health Record-Chronological Record of Medical Care) at the Battalion Aid Station (BAS) level and above, ensuring that a comprehensive record accompanies the patient throughout their care journey or remains at the BAS as determined by the patient's disposition. As such, it is an indispensable document for healthcare providers in the military, facilitating not only immediate care decisions but also contributing to the broader healthcare management and audit system.

QuestionAnswer
Form NameDa Form 5181 R
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesadtmc army 2019, adtmc app, adtmc 2019, adtmc pdf

Form Preview Example

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SCREENING NOTE OF ACUTE MEDICAL CARE

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.

TIME PATIENT DEPARTS UNIT

(From DD Form 689)

SCREENER LOCATION

TIME PATIENT ARRIVES

TIME ENCOUNTER BEGINS

TIME PATIENT LEAVES

 

 

 

SCREENER LOCATION

CHIEF COMPLAINT

DURATION

PATIENT RESIDENCE

 

 

VITAL SIGNS

 

 

 

 

 

 

 

( ) BARRACKS

( ) POST HOUSING

TEMPERATURE

 

 

 

 

ALLERGIES

 

( ) OFF POST

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) TRANSIENT

PULSE

 

BP

 

RESP

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST VISIT FOR THIS COMPLAINT (

) YES ( ) NO IF NO, WAS RETURN SCHEDULED/REQUESTED BY CARE PROVIDER?

( ) YES ( ) NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALGORITHM/CODE

 

 

 

ALGORITHM/CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

ALGORITHM SUMMARY

 

 

ALGORITHM SUMMARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS (Reasons for referral, method of referral, hospital appointments, self-care protocols, and patient instructions/precautions)

PATIENT'S IDENTIFICATION (Use mechanical imprint if available, for typed or written entries give: Name, SSN, Unit, Sex, Birthdate and

Duty Phone)

FINAL DISPOSITION

 

 

( )

I - PHYSICIAN STAT

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IV - SELF CARE PROTOCOL

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II - PA STAT

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) V - HOSP CLINIC REFERRAL

 

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) III - PA

 

 

AIDMAN'S SIGNATURE & CODE

AUDITOR'S INITIALS & DATE

DA FORM 5181-R, OCT 86

PREVIOUS EDITIONS OF THIS FORM ARE OBSOLETE.

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RECORD OF ACUTE MEDICAL CARE

(Entries on this record should be restricted to further evaluation and treatment of complaint(s) screened)

DATE

2ND CARE LOCATION

TIME PATIENT ARRIVES

TIME ENCOUNTER BEGINS

TIME PATIENT LEAVES

SIGNATURE OF HEATH CARE PROVIDER

SIGNATURE OF MEDICAL SUPERVISOR

AUDITOR'S INITIALS AND DATE

SPECIAL INSTRUCTIONS

This form will be utilized in lieu of SF 600 (Health Record-Chronological Record of Medical Care) at the BAS level and above when care is initiated by an ADTMC screener. The record of acute, medical care will accompany the patient to the next level of care or remain in the BAS depending on disposition reached. This form will be filed in the HREC when evaluation and audit are completed.

REVERSE OF DA FORM 5181-R

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