PATIENT MOVEMENT RECORD DATA PROTECTED BY PRIVACY ACT OF 1974

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August Blaise Melton
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1 SECTION I PATIENT MOVEMENT RECORD DATA PROTECTED BY PRIVACY ACT OF 1974 PERMANENT MEDICAL RECORD (S) - Information needed to submit patient movement record PATIENT IDENTIFICATION (s) NAME (Last, First, Middle Initial) (s) SSN DATE OF BIRTH (s) AGE (s) SEX (s) STATUS (s) SERVICE M F SECTION II (s) Medical Treatment Facility Origination and Phone Number (s) GRADE (s) UNIT OF RECORD AND PHONE NUMBER VALIDATION INFORMATION (s) Ready Date (Julian Date) APPOINTMENT DATE CITE NUMBER NUMBER OF ATTENDANTS (s) MEDICAL (s) NON-MED (s) Medical Treatment Facility Destination and Phone Number (s) CLASSIFICATION 1A-5F AMBULATORY LITTER (s) PRECEDENCE (s) Reason Regulated Max # Stops Max # RONS Altitude Restriction (s) CCATT Required Name, sex, weight, rank of attendants: U P R yes no SECTION III (s) Attending Physician name, Phone Number and OTHER INFORMATION (s) Accepting Physician name, Phone Number and (s) Origination Transportation 24 Hour Phone Number (s) Destination Transportation 24 Hour Phone Number (s) Insurance Company Address Phone # Policy # Relationship to policy holder (s) Waivers (med equip, etc) SECTION IV (s) Diagnosis (s) Allergies CLINICAL INFORMATION LABS (Date and time drawn in Zulu) WBC HGB HCT Other Labs (s) WEIGHT: (S) Blood type: Vital Signs (Date and time taken in Zulu) battle casualty disease Date Time (Zulu) B/P Pulse Resp Pain Level: Last Pain Med: O 2 /LPM: Route: non-battle injury /10 CLINICAL ISSUES Baseline 02 Sat If Applicable Temp Infection Control Precautions: LMP: SPECIAL EQUIPMENT (Check all that apply) Suction Traction Orthopedic devices OTHER: Date of last bowel movement: NG Tube Monitor Restraints High Risk for Skin Breakdown yes no Foley Trach Chest Tubes Initial appropriate boxes: Yes No SECTION V Hearing Impaired Communication Barriers Vision Impaired Cardiac Hx Diabetes Motion Sickness Ears/Sinus Problems Respiratory difficulty Yes No Dizziness *Medication listed on physician's orders Hypertension Voiding difficulty *Takes long-term meds *Will self-medicate Has adequate supply of meds Knows how to take meds (verbalized understanding) Incubator Cast Location: Ventilator NPO Renal Tube Feeding Cardiac TPN: Other(specify): IV Pumps Ventilator Settings: IV Location: DIET INFORMATION (Check all that apply) Soft Gm Protein Type Full Lig Gm Na PERTINENT CLINICAL HISTORY(Transfer Summary) cc/hr Bivalved: yes no CI Liq Meq K Reg Mag Sulfate Discontinue for Flight Diabetic cal Infant formula: Pediatric Age: Physician's Signature Date/Time Signature of Clearing Flight Surgeon Date/Time AF IMT 3899, , V1

2 PATIENT MOVEMENT RECORD (continuation) DATA PROTECTED BY PRIVACY ACT OF 1974 PERMANENT MEDICAL RECORD PATIENT MOVEMENT PHYSICIAN ORDERS ( for continued care in the AE system and at enroute stops) SECTION I. PATIENT IDENTIFICATION 1. NAME (Last, First, Middle Initial) 2. GRADE 3. SSN# 4. ALLERGIES 5. ORIGINATING MTF 6. DESTINATION MTF SECTION II. yes no MEDICATION ORDERS (Drugs and IVs) patient will self-medicate with the following medications: SECTION III. OTHER ORDERS (Procedures, Treatment, V/S Frequency, ETC) AF IMT 3899, , V1 (REVERSE)

3 TPMRC-WEST Step-By-Step How To Fill Out and Review AF IMT 3899 For Mil Air Evac Requirements

4 AF IMT 3899 Requirements Below you will find instructions on how to review a Items marked with * are required for validation (Page 1) Section I Patient Identification *Name: Patient s name as it appears on their DoD ID card. *SSN: Patient s FULL social security number. Ensure it is the patient s ACTUAL SSN and not the sponsor s. *Date of birth *Age: Age of the patient at the moment the 3899 is being completed. *Sex *Status: AD, Ret, Dep, Civ, VA Service: USN, Army, AF, Civ Grade: Rank Unit of record: Only applicable for AD patients. Cite number: Must match TRAC2ES. Section II

5 Validating Information *Medical Treatment Facility Origination and Phone Number: MTF where patient is receiving treatment. *Medical Treatment Facility Destination and Phone Number: MTF where patient will receive definitive treatment. *Ready date: Julian Date when patient will be ready for movement. *Appointment date: Only required for outpatients. *Classification 1A-5F: See attachment 1. Be advised that TPMRC s validating flight surgeon might change patient classification after reviewing it. *Check AMBULATORY or LITTER box Please make sure it matches the Pts classification *Number of Attendants. Please be advised that an exception to policy will be required if more than 1 nonmedical attendant will be traveling with patient. *CCATT required: check yes or no. *Name, sex, weight, rank of attendants: must match TRAC2ES. If there is not enough space in this box, use Section III in the back page. *Precedence: check Urgent(U) within 12hrs, Priority(P) within 24hrs or Routine(R) next scheduled mission. Section III Other Information *Attending Physician name, phone number and Sending physician currently caring for the patient. Phone number must be a cell phone or personal office to facilitate communication if needed. *Accepting physician name, phone number and Physician who has accepted patient for definitive treatment at final destination MTF. Phone number must be cell phone or personal office to facilitate communication.

**If patient will be remaining overnight at any MTF s while on his/her way to final destination MTF, please annotate RON (remain overnight) accepting providers and their phone number in Section III

*Vital signs: Date (must be within 30 days for outpatient and within 7 days for inpatients). B/P: if not within normal range, explanation must be in TRAC2ES PMR (hx of hypertension? Being treated?

6 **If patient will be remaining overnight at any MTF s while on his/her way to final destination MTF, please annotate RON (remain overnight) accepting providers and their phone number in Section III on the back of 3899** Section IV Clinical Information *Diagnosis: Diagnosis/ICD10 code. *Allergies: annotate any medication or food allergies. *Labs: If required. Must be most current labs taken. *Vital signs: Date (must be within 30 days for outpatient and within 7 days for inpatients). B/P: if not within normal range, explanation must be in TRAC2ES PMR (hx of hypertension? Being treated?) Pulse Resp rate Pain level Last pain med: required if patient in pain/ has PRN pain medications ordered. O2/LPM: Only required if patient is on supplemental O2; how many LPM was the pt. on when SpO2 taken. Route: Nasal cannula, Non-rebreather. Only required for patients on oxygen. Baseline O2 Sat: Required for all patients (95-100%) Temp *Special Equipment: check all that apply. If patient needs an equipment not listed, annotate it on the box marked Other. *IV location: annotate if applicable.

7 *Cast location: if applicable. *Ventilator settings: if applicable. **Some special equipment will need waivers for travel. Some examples of such special equipment are glucometers and CPAP machines. If an equipment waiver is required, TPMRC will ask for equipment model manufactures and serial number** Clinical issues: check ALL yes or no boxes. Inpatients will NOT self medicate per regulation. *Diet information: check appropriate box. List any food allergies. Section V Pertinent Clinical History Case-specific Required Info/orders/instructions for Movement Request: a) Include event/procedure dates, initial and ongoing Sx/Si, significant Comorbidities (and how well controlled), and any justification for special needs. b) PMR & 3899 Hx intended to quickly orient en-route care-givers (flight surgeons and flight nurses) and show that the patient requires movement and is stable enough for movement. c) Standard good-idea orders: **O2 1-6L NC prn to keep SpO2 >93% in-flight **Zofran 4mg PO/IV pre-flight or PRN in-flight *Pertinent Clinical History: Clear and concise summary of reason for evacuation. Must include dates, diagnosis and findings, as well as patient s current condition. *Physician s signature: MUST be signed and stamped by sending physician. Date must be within 30 days. *Signature of clearing flight surgeon: MUST be signed and stamped by clearing flight surgeon. Date must be within 30 days.

PRN for nausea Accuchecks Q AC + HS Morphine 2-8mg IV Q3H PRN severe pain Dressing changes Q12hrs @ enroute stops Ativan 2mg PO X1 give 30 min prior to flight Neuro

8 3899 (Page 2) Section 1 Patient Identification *All information MUST match first page and TRAC2ES PMR. Section II Medication Orders Example of Legal Medication Orders: Example of other Orders: Lisinopril 40mg PO Daily O2 2-6L NC PRN keeps stats > 93% Zofran 4mg PO Q8H PRN for nausea Accuchecks Q AC + HS Morphine 2-8mg IV Q3H PRN severe pain Dressing changes enroute stops Ativan 2mg PO X1 give 30 min prior to flight Neuro checks Q4H Insulin Sliding Scale Blood Sugar Dose < 60 Call Physician No Insulin Units Units Units Units Units > Units (Call Physician) **Must have flight approved Glucometer**

*Medication orders: List of all medications patient is taking (scheduled or PRN). Dose, route and frequency are required for all medications and must be a legal medication order.

9 *Medication orders: List of all medications patient is taking (scheduled or PRN). Dose, route and frequency are required for all medications and must be a legal medication order. PRN medications must indicate why it is given (example: Tylenol 650mg PO q 6hrs PRN for headache, Morphine 4mg IV Q3H PRN severe pain, Oxycodone 10mg PO Q4H PRN pain). *If glucose is required, sliding scale must be annotated under medication orders. *Check Yes or No for Will Self-Medicate Must match front of **ALL medication orders must match PMR in TRAC2ES** Section III Other Orders *Supplemental oxygen order is required for all patients traveling via Mil air Complete O2 order (O2 2-6L NC PRN to keep Sats >93%). *Any additional information not covered in previous sections. Examples: Vital Signs frequency, procedures (like wound dressing, ect). Ventilator settings, TPN settings. RON provider information (name and phone number). **ALL orders must be annotated in PMR also**

10 ATTACHMENT 1 Patient Classification 1A 1B 1C 2A 2B 3A 3B 3C 4A 4B 4C 4D 4E 5A 5B 5C 5D 5E 5F 6A 6B Severe psychiatric inpatient. Requires litter, restraints in place, sedation, and close medical supervision at all times. Intermediate psychiatric inpatient. Requires litter, sedation, and close medical supervision at all times. Restraints must be kept nearby and available. Moderate psychiatric inpatient. Cooperative and reliable. Will walk aboard; kept under observation. Litter-bound inpatient (non-psychiatric) who cannot ambulate. Litter-bound inpatient (non-psychiatric) who can egress in an emergency. Inpatient, Ambulatory inpatient (non-psychiatric, non-substance abuse) going for treatment. Inpatient, Recovered inpatient, returning to home station. Inpatient, Ambulatory inpatient going for substance-abuse treatment. Child <3 years, inpatient, using aircraft seat, going to treatment Child <3 years, inpatient, using aircraft seat, returning to home station Child <3 years, requires incubator/neonatal Transport System (NTS) Child <3 years, inpatient, litter-bound Child <3 years, outpatient Outpatient, ambulating, non-psychiatric/non-substance abuse, going to treatment Outpatient, going for substance-abuse treatment Outpatient, going for psychiatric treatment or evaluation Outpatient, litter-for-comfort, going for treatment Outpatient, litter-for-comfort, returning home from treatment Outpatient, ambulating, returning home from treatment Medical attendant to a patient Non-medical attendant to a patient

Neighborhood Hospital

Neighborhood Hospital Physician Progress Notes Time Mon S/P HoLEP Procedure without complications; estimated blood loss < 100 ml; stable condition to recovery room. 1530 To be admitted to Urology following PACU. Dan Stein,