US Army Medical Course MD0753-101 Book1 - Medical Records Administration Branch

U. S.
ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

FORT SAM HOUSTON, TEXAS 78234
MD0753
MEDICAL RECORDS
ADMINISTRATION BRANCH I
(BOOK 1 OF 2)
EDITION 101
DEVELOPMENT
This subcourse reflects the current thought of the Academy of Health Sciences and
conforms to printed Department of the Army doctrine as closely as currently possible.
Development and progress render such doctrine continuously subject to change.
When used in this publication, words such as "he," "him," "his," and "men" are intended to
include both the masculine and feminine genders, unless specifically stated otherwise
or when obvious in context.
The contractor responsible for the development of this subcourse was Advanced
Development Group. The instructional systems specialist responsible for overseeing
development was Mr. Richard Smart, DSN 421-9931; commercial (210) 295-9931, and the
subject matter expert responsible for content accuracy was SFC Mark Minter, DSN 471-
0944; commercial (210) 221-0944, COMMANDER, U.S. ARMY MEDICAL DEPARTMENT
CENTER AND SCHOOL, DEPARTMENT OF HEALTHCARE OPERATIONS, ATTN:
MCCS-HHP, 3151 SCOTT ROAD, FORT SAM HOUSTON, TX 78234-6100.
ADMINISTRATION
Students who desire credit hours for this correspondence subcourse must meet eligibility
requirements and must enroll through the Nonresident Instruction Branch of the U.S. Army
Medical Department Center and School (AMEDDC&S).
Application for enrollment should be made at the Internet website: http://www.atrrs.army.mil.

You can access the course catalog in the upper right corner. Enter School Code 555 for
medical correspondence courses. Copy down the course number and title. To apply for
enrollment, return to the main ATRRS screen and scroll down the right side for ATRRS
Channels. Click on SELF DEVELOPMENT to open the application and then follow the on
screen instructions.
In general, eligible personnel include enlisted personnel of all components of the U.S. Army
who hold an AMEDD MOS or MOS 18D. Officer personnel, members of other branches of
the Armed Forces, and civilian employees will be considered eligible based upon their AOC,
NEC, AFSC or Job Series which will verify job relevance. Applicants who wish to be
considered for a waiver should submit justification to the Nonresident Instruction Branch at
e-mail address: accp@amedd.army.mil.
For comments or questions regarding enrollment, student records, or shipments, contact

the Nonresident Instruction Branch at DSN 471-5877, commercial (210) 221-5877, toll-free
1-800-344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail accp@amedd.army.mil, or
write to:
NONRESIDENT INSTRUCTION BRANCH

AMEDDC&S
ATTN: MCCS-HSN
2105 11TH STREET SUITE 4191
FORT SAM HOUSTON TX 78234-5064
TABLE OF CONTENTS
Lesson Paragraphs Page
INTRODUCTION ............................................................................ v
1 INPATIENT TREATMENT RECORDS........................................ 1-1--1-20 1-1
Section I. Background Information..................................... 1-1--1-4 1-2

Section II. Variations of Inpatient Treatment Records ...... 1-5--1-9 1-4
Section III. Essential Elements............................................. 1-10--1-17 1-7
Section IV. Filing and Disposition ........................................ 1-18--1-20 1-30
Exercises ..................................................................................... 1-37
2 DIAGNOSTIC AND OPERATIVE CODING................................ 2-1--2-19 2-1
Section I. General ................................................................ 2-1--2-6 2-2

Section II. Conventions and Terminology........................... 2-7--2-12 2-6
Section III. Use of ICD-9-CM................................................ 2-13--2-19 2-12
Exercises ..................................................................................... 2-22
3 INPATIENT TREATMENT RECORD COVER SHEET............. 3-1--3-6 3-1

Section II. Completion of the Inpatient Treatment
Record Cover Sheet........................................... 3-4--3-6 3-5
Exercises ..................................................................................... 3-17
4 INDIVIDUAL PATIENT DATA SYSTEM...................................... 4-1--4-109 4-1

Section II. Coding of DA Form 2985 .................................. 4-6--4-84 4-9
Section III. Coding of the A&C Form From the U.S.
Field Medical Card (FMC)................................. 4-85--4-107 4-76
Section IV. Transmittal Procedures and Data Access....... 4-108--4-109 4-83
Exercises ..................................................................................... 4-85
* Appendices under separate cover (Book 2 of 2)
MD0753 i
LIST OF FIGURES
Figure Page
1-1 Completed DA Form 3444-6 used as an Inpatient Treatment Record.............. 1-3

1-2 DA Form 3647 (Inpatient Treatment Record Cover Sheet) ................................ 1-8
1-3 OF 275 (Medical Record Report) .......................................................................... 1-9
1-4 SF 539 (Abbreviated Medical Record)................................................................. 1-10
1-5 SF 504 (History - Part 1) ........................................................................................ 1-14
1-6 SF 505 (History - Part 2)......................................................................................... 1-15
1-7 SF 505 (History - Part 3)......................................................................................... 1-16
1-8 SF 506 (Physical Examination).............................................................................. 1-17
1-9 SF Form 509 (Doctor's Progress Notes).............................................................. 1-18
1-10 DA Form 4256 (Doctor's Orders) .......................................................................... 1-21
1-11 SF 510 (Nursing Notes) .......................................................................................... 1-22
1-12 SF 516 (Operation Report)..................................................................................... 1-24
1-13 SF 515 (Tissue Examination)................................................................................. 1-25
1-14 SF 522 (Request for Administration of Anesthesia and
for Performance of Operations and Other Procedures) .................................... 1-26
1-15 SF 517 (Anesthesia Form)..................................................................................... 1-27
1-16 SF 502 (Narrative Summary) ................................................................................. 1-29
2-1 Volume 1, Table of Contents (Continued)............................................................. 2-4

2-2 ITRCS (handwritten and typed copies).................................................................. 2-13
2-3 Example of alphabetical arrangement of Volume 2, ICD-9-CM (showing
indentation of main terms and modifiers)............................................................ 2-16
2-4 Volume 3, Example of alphabetic arrangement of Vol. 2, ICD-9-CM................ 2-19
3-1 DA Form 3647 (Inpatient Treatment Record Cover Sheet for typed
entries) .................................................................................................................... 3-7
3-2 DA Form 3647 (Inpatient Treatment Record Cover Sheet for computer
generated entries) ................................................................................................. 3-8
3-3 Relationship of DA Form 2985 and DA Form 3647............................................ 3-9
3-4 DA Form 3647 for Exercise 17.............................................................................. 3-21
3-11 DA Form 3647, Solution for Exercise 20 .............................................................. 3-30
MD0753 ii
LIST OF FIGURES
Figure Page
4-1 DA Form 2985 (Admission and Coding Information) .......................................... 4-5

4-2 DA Form 3647 (Inpatient Treatment Record Cover Sheet-typed) ..................... 4-8
4-3 Julian Date Calendar (Perpetual) .......................................................................... 4-70
4-4 DD Form 1380 (U.S. Field Medical Card)............................................................ 4-78
4-5 DA Form 3647, Inpatient Treatment Record Cover Sheet.................................. 4-89
4-6 DA Form 2985 for Exercise 21 (continued).......................................................... 4-90
4-8 DA Form 2985 for Exercise 21 (concluded)......................................................... 4-92
4-9 DA Form 3647, Inpatient Treatment Record Cover Sheet.................................. 4-94
MD0753 iii
LIST OF TABLES
Table Page
1-1 Filing sequence for documents in ITR folder............................................................1-31
3-1 Abbreviations used on the ITRCS.............................................................................3-4
4-1 Medical treatment facility (MTF) codes .................................................................. 4-10

4-2 State location codes...................................................................................................4-11
4-3 Grade codes ...............................................................................................................4-13
4-4 Sex codes....................................................................................................................4-15
4-5 Age codes ...................................................................................................................4-17
4-6 Race codes .................................................................................................................4-17
4-7 Ethnic background codes ..........................................................................................4-18
4-8 Religion abbreviations ...............................................................................................4-19
4-9 Length of service codes.............................................................................................4-21
4-10 Family member prefix (FMP) codes.........................................................................4-22
4-11 Marital status codes ...................................................................................................4-24
4-12 Categories of U.S. Uniformed Services Personnel................................................4-26
4-13 Department/type of beneficiary codes .....................................................................4-27
4-14 Trauma codes .............................................................................................................4-35
4-15 Source of admission codes.......................................................................................4-37
4-16 Disposition type codes ..............................................................................................4-39
4-17 First position MTF codes...........................................................................................4-42
4-18 Medical Expense and Performance Reporting System (MEPRS) clinic
service codes............................................................................................................4-44
4-19 Underlying cause of death/separation codes ..........................................................4-53
4-20 Place of occurrence of injury third-digit codes ........................................................4-55
4-21 Place of treatment codes...........................................................................................4-57
4-22 Surgical procedures place of performance codes..................................................4-59
MD0753 iv
CORRESPONDENCE COURSE OF
THE ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL
SUBCOURSE MD0753
MEDICAL RECORDS ADMINISTRATION BRANCH I
INTRODUCTION
The Inpatient Treatment Record (ITR) is prepared for all patients admitted to a medical
treatment facility (MTF). This ITR is used to provide a record of patient care and treatment;
to plan patient care; and to serve as a communication device between the physician and
other health care professionals. The diagnosis and medical procedures performed on an
inpatient are numerically coded for input into the Individual Patient Data System (IPDS), a
computer system for the collection of statistical information. Through this system, statistical
information is obtained for planning, managing, and evaluating the Army Medical
Department medical care system for medical and epidemiological research. The IPDS
also is a source of data for the Medical Command, Office of The Surgeon General, and
other relevant requestors; and for management reports for the hospital commander and his
staff.
This subcourse will explain the procedure for maintaining and controlling Inpatient
Treatment Records; coding diagnosis and procedures on the Inpatient Treatment Record
Cover Sheet (ITRCS); preparing the coding information forms; and for disposing of the
ITRs. This subcourse will familiarize you with the tasks performed in the Medical Records
Administration Branch and will enhance your skill and proficiency in performing these
tasks.
Subcourse Components:
Subcourse MD0753 consists of four lessons and an examination (Book 1 of 2), and
appendices under separate cover (Book 2 of 2). The lessons are:
Lesson 1, Inpatient Treatment Records.
Lesson 2, Diagnostic and Operative Coding.
Lesson 3, Inpatient Treatment Record Cover Sheet.
Lesson 4, Individual Patient Data System.
Credit Awarded:
You will be awarded 20 credit hours for the successful completion of this subcourse.
Lesson Materials Furnished:
Materials provided include this booklet, an examination answer sheet, and an envelope.
(The examination is included in this booklet.) No other text is required. You must furnish a
#2 pencil.
MD0753 v
The exercises and solutions for all exercises are also contained in this booklet. Answer
sheets are not provided for the exercises. You are encouraged to complete the subcourse
lesson by lesson.
Procedures for Subcourse Completion:
You will submit your examination answer sheet to the AMEDDC&S for grading. When you
have completed the examination exercises to your satisfaction, fill out the enclosed
examination answer sheet and mail it to the AMEDDC&S in the envelope provided. You
will be notified by return mail of the results. Include your social security number on all
correspondence sent to the AMEDDC&S. The grade you make on the examination will be
your rating for the subcourse.
Study Suggestions:
We suggest that you follow these study procedures:
--Read and study each lesson assignment carefully.
--Complete the lesson exercises for the first lesson, marking your answers in this
booklet. Refer to the text material as necessary.
--When you have completed the exercises to your satisfaction, compare your answers
with the solution sheet located at the end of the lesson. Check the references for your
incorrect answers.
--After you have successfully completed one lesson, go on to the next and repeat the
above procedures.
--When you feel confident that you have mastered the study materials, complete the
examination. We suggest that you complete the examination by first marking each answer
in this booklet. When you have responded to each item to your satisfaction, transfer your
responses to the examination answer sheet and mail it to the AMEDDC&S for grading.
Student Comment Sheet:
A Student Comment Sheet is located at the back of this booklet. It is to be returned with
your examination answer sheet. As you study the subcourse, you may wish to make
suggestions or comments which will help us to improve the quality of the subcourse.
MD0753 vi
LESSON ASSIGNMENT
LESSON 1 Inpatient Treatment Records.
LESSON ASSIGNMENT Paragraphs 1-1 through 1-20.
LESSON OBJECTIVES After completing this lesson, you should be able to:
1-1. Identify the functions of the Inpatient Treatment

Record.
1-2. List the essential elements of the Inpatient

Treatment Record.
1-3. Identify the correct sequence of forms filed in the

Inpatient Treatment Record.
1-4. Identify the variations of the Inpatient treatment

Record.
1-5. Identify the disposition of Inpatient Treatment

Records.
SUGGESTION After reading and studying the assignment, complete

the exercises of this lesson. These exercises will help
you to achieve the lesson objectives.
MD0753 1-1
LESSON 1
INPATIENT TREATMENT RECORDS
Section I. BACKGROUND INFORMATION
1-1. PURPOSE
a. Medical Record. As explained in Subcourse MD0750, Introduction to Medical

Records and The Patient Administration Division, dated 1998, a medical record is any
military or civilian document that provides information on the evaluation, findings,
diagnosis, and treatment of a patient. Included as medical records are the Inpatient
Treatment Record, the Outpatient Treatment Record, the Health Record, Civilian Employee
Medical Record, and Alcohol and Drug Abuse Prevention and Control Program Outpatient
Medical Records.
b. Inpatient Treatment Record (ITR). The ITR is the record used at a medical
treatment facility (MTF) that has authorized beds for inpatient medical care. This record is
initiated upon the patient's admission to an MTF and is completed when his hospitalization
is terminated. This record is used for all beneficiary categories, military or civilian.
c. Purpose. The purpose of an ITR is to:
(1) Provide a complete medical history on the management (including

observations treatments, and care) of a patient while he is hospitalized.
(2) Communicate with all health care providers who interface with the patient.
(3) Provide medico-legal support for the care provided.
(4) Provide information (as needed) for education and research.
1-2. FORMS
The DA Form 3444-series (Terminal Digit File Folder) is initiated when an inpatient
treatment record is required (see para 1-4). The same preparation instructions outlined in
Subcourse MD0751, Outpatient Medical Records Branch, dated 1998, apply to the
Inpatient Treatment Record (ITR). All authorized forms are fastened into the DA Form
3444-series file folder. The filing sequence of these forms within the folder is covered later
in this lesson. Figure 1-1 shows a completed DA Form 3444-series used as a file folder
for an Inpatient Treatment Record.
MD0753 1-2
Figure 1-1. Completed DA Form 3444-6 used as a file folder for an Inpatient
Treatment Record.
1-3. RESPONSIBILITIES
a. MTF Commander. The commander of the medical treatment facility (MTF) is

the official custodian of the medical records (including the ITR) at the facility. Each MTF
commander is responsible for ensuring that adequate and timely Inpatient Treatment
Records are prepared for each patient who is required to have one.
b. Chief, Patient Administration Division (PAD). The Chief, PAD acts for the
commander in matters of handling ITRs and is responsible for keeping the professional
staff informed on the requirements for ITRs.
MD0753 1-3
c. Professional Staff. Health care providers (doctors and nurses) must record
promptly and correctly all patient observations, treatments, and care provided to the
patient. This data becomes part of the Inpatient Treatment Record.
1-4. FOR WHOM PREPARED
a. An Inpatient Treatment Record is prepared for:
(1) Every bed patient (military or civilian) in a hospital, fixed health clinic, or
convalescent center.
(2) Each live born infant delivered in one of the above medical treatment
facilities.
(3) Carded for Record Only (CRO) cases when the patient will not occupy a bed
but an inpatient record must be initiated.
b. An Inpatient Treatment Record is not prepared for:
(1) Stillbirths (delivery of a dead infant).
(2) Patients treated in MTFs supporting combat operations when U.S. Field
Medical Cards are used.
c. When patients are transferred, their ITRs are sent to the patient administrator at
the next medical treatment facility.
Section II. VARIATIONS OF INPATIENT TREATMENT RECORDS
1-5. TYPES OF INPATIENT TREATMENT RECORDS
The nature of the case (type of illness or injury) or the length of stay determines
whether a routine Inpatient Treatment Record, an Abbreviated Inpatient Treatment Record,
or a Carded for Record Only Inpatient Treatment Record is initiated for the patient.
1-6. ROUTINE INPATIENT RECORD
a. A routine Inpatient Treatment Record is required for patients receiving long-term

care. (If a patient is hospitalized for more than 72 hours, his case is classified as long-term
care.)
MD0753 1-4
b. A routine Inpatient Treatment Record is required if a patient has a serious
illness, such as a heart attack or pneumonia.
c. A routine Inpatient Treatment Record is also required for a patient having major
surgery.
d. Often, more than one of these criteria may be present. Major surgery generally
requires more than 72 hours of care. A serious illness may also require more than 72
hours of care, and a serious illness may also require major surgery.
1-7. ABBREVIATED MEDICAL RECORD
a. SF 539 (Abbreviated Medical Record) may be used for cases of a minor nature
that require no more than 72 hours' hospitalization. It may be used for accident cases held
for observation, removal of superficial growths, or application of plaster casts.
b. If general anesthesia is given, the surgical process must be localized and should
not entail a systemic invasion. SF 539 may be used for cases in which general anesthesia
is given only if the patient has no organic, physiologic, biochemical, or psychiatric
disturbance.
c. When military personnel are hospitalized for uncomplicated conditions not usually
requiring hospitalization for civilians, such as measles or upper respiratory infections, SF
539 will be used. If the hospital stay exceeds 72 hours, the reason for the extended stay
will be fully recorded in the progress notes and a narrative summary must be prepared.
1-8. CARDED FOR RECORD ONLY (CRO)
A case is carded for record only when a patient is not admitted to the hospital but
the preparation of a DA Form 3647 (Inpatient Treatment Record Cover Sheet) and the
assignment of a register number are required. Examples of CRO cases are:
a. Patients who are dead upon arrival (DOA) at the medical treatment facility.
b. Medical board examinations performed in an outpatient facility.
c. Certain other cases considered by the MTF to have medical, legal, or other
significance, such as rape, assault, and driving while intoxicated (DWI). The Medical
Records Committee establishes guidelines for these cases.
MD0753 1-5
1-9. FORMS REQUIRED FOR ITRs
a. The forms and reports filed in an Inpatient Treatment Record (ITR) depend on the
nature of the case and the treatment given. All forms and reports needed for a case must
be included in the ITR.
b. DA Form 3647, Inpatient Treatment Record Cover Sheet (ITRCS), is initiated in

the admitting office. When the patient is discharged, the attending physician will complete
the "worksheet" and prepare SF 502, Narrative Summary. He will then send the completed
"worksheet" to the Patient Administration Division (PAD) where the information is keyed
into the computer in final form. Two copies of the Inpatient Treatment Record Cover Sheet
(ITRCS) must be prepared for each hospitalization and included in all ITRs. Details about
the use of the Inpatient Treatment Record Cover Sheet are given in lesson 3 of this
subcourse.
c. The forms used for various types of ITRs are described below:
(1) Routine Inpatient Treatment Record.
(a) *DA Form 3647 (Inpatient Treatment Record Cover Sheet) is placed at
the front of the folder. (See figure 1-2.)
(b) Next, are filed all Standard Forms, such as SF 502 (Clinical
Record-Narrative Summary or OF 275 used to transcribe the narrative summary).
(c) OF 275 (Medical Record Report) is a continuous form used to print

transcription of dictated reports. When OF 275 is used in place of one of the standard
forms, the number of the form it replaces will be marked in the lower left-hand corner and
OF 275 will be filed as if it were the form it replaces. (See figure 1-3.)
(d) Then, all DA Forms, such as DA Form 4256 (Doctor's Orders) are filed.
(e) Then, all DD Forms, such as DD Form 741 (Eye Consultation) are filed.
(f) Finally, if there are unnumbered forms, they are filed after the DD forms.
Details about the sequence of forms which make up the ITR are provided later in this
lesson.
(2) Abbreviated Inpatient Treatment Record.
(a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover
Sheet) are placed at the front of the folder.
(b) SF 539 (Abbreviated Medical Record) is filed next. This form replaces
several other forms used in the routine ITR. (See figure 1-4.)
MD0753 1-6
(3) Carded for record only (CRO).
(a) Two copies of *DA Form 3647 (Inpatient Treatment Record Cover
Sheet) are placed at the front of the folder.
(b) Then, other forms as applicable are filed (for example, a copy of the
death certificate for a DOA case).
* In facilities using the Composite Health Care System (CHCS) or Automated Quality of
Care Evaluation Support System (AQCESS), an automated version of DA Form 3647 will
be used. The worksheet copy will not be provided.
Section III. ESSENTIAL ELEMENTS
1-10. GENERAL
a. Content. Entries are made in a medical record by the health care provider
observing, treating, or caring for the patient. Entries on the Inpatient Treatment Record
Cover Sheet (ITR) or on any medical form provide a useful record for continued and future
care; therefore, all entries must be relevant to actual observation and treatment of the
patient, and the record must be current.
b. Legibility. All entries in the ITR must be legible. They should be in typewritten
form, when possible. When hand-written, entries must be made in permanent black or
blue-black ink; rubber stamps may be used only for standardized entries. Certain forms,
such as radiology, pathology, and operative reports, and the narrative summary, must be in
typewritten form. These are usually dictated and transcribed onto Optional Form 275
(Medical Record Report).
c. Signatures. All entries in the ITR must be signed; later entries on the same
page by the same person must be signed or initialed. A military member must add grade
and corps; a civilian must add title or certification. Rubber-stamped signatures may not be
used in place of written signatures or initials. The use of rubber block stamps under the
written signature is recommended because it provides a means of identifying the person
making the entry.
MD0753 1-7
Figure 1-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet).
MD0753 1-8
Figure 1-3. OF 275 (Medical Record Report).
MD0753 1-9
Figure 1-4. SF 539 (Abbreviated Medical Record) (continued).
MD0753 1-10
Figure 1-4. SF 539 (Abbreviated Medical Record) (concluded).
MD0753 1-11
d. Dating Entries. All entries in the ITR must be dated. Dates should be written in
a day-month-year sequence, and months designated by name--not by number.
e. Corrections to Entries. To correct an entry in the ITR, a single line should be

drawn through the incorrect information. (The crossed-out information should remain
readable.) Then, the new information should be added, dated, and signed, with title, by the
person making the correction.
1-11. IDENTIFICATION OF PATIENT
a. The "Patient Identification" section on each form and report in the ITR must be
completed. Usually, the patient's admitting plate and a mechanical device are used to
imprint this section. At a minimum, the patient identification must include: patient's name;
rank, grade, or status; family member prefix; sponsor's social security number (SSN); and
register number.
b. Two copies of the Inpatient Treatment Record Cover Sheet (ITRCS) are placed
at the front of each ITR. The ITRCS is computer-generated in hospitals and medical
centers with this capability. Regardless of the process, the ITRCS, as well as other forms,
must have complete patient identification.
1-12. ADMISSION HISTORY AND PHYSICAL EXAMINATION
a. History. An admission history must be written within 24 hours of the patient's

admission. SF 504 (see figure 1-5) and SF 505 (see figure 1-6 and figure 1-7) are used
for the history. The history is recorded by a staff physician, a resident, or a physician
assistant (PA). When recorded by a physician assistant, the history must be reviewed by
an attending physician and countersigned.
b. Physical Examination. The ITR must also contain a thorough physical

examination recorded on SF 506 (see figure 1-8). The examination must be current (that
is, it must have been completed within the preceding 24 hours); it must be related to the
illness for which the patient is hospitalized; and the findings must be recorded in specific
terms.
1-13. SF 509 (DOCTOR's PROGRESS NOTES)
a. General. Progress notes chronologically describe the clinical status of the

patient. They must reflect any change in the patient's condition and the results of treatment
and must be recorded by the person giving the treatment or making the observation.
MD0753 1-12
b. Progress Notes by Physician. The physicians' notes are documented on SF
509 (see figure 1-9). They provide an analysis of the patient's clinical course and outline
the rationale for specific medical decisions. Physicians' notes begin with an admission
note, continue with notes during hospitalization, and conclude with a note on discharge or
death.
(1) The admission note should briefly record the clinical circumstances that
brought the patient to the hospital, summarize the proposed diagnostic workup, and
suggest the type of therapeutic management. For emergency patients admitted, SF 558
(Emergency Care and Treatment) may be used as the admission note and placed in the
ITR.
(2) For surgical patients, the admission note may serve as the preoperative
note. In addition to giving the information described in paragraph 1-13b(1), these notes
must justify the surgery and state the procedure proposed.
(3) The physician or nurse anesthetist's preanesthesia note is recorded on SF

509 or SF 517 (Anesthesia Form), as appropriate. It should explain the choice of
anesthesia for the proposed procedure. The postanesthesia note must be made after the
patient has left the recovery area and must record the presence or absence of
anesthesia-related complications.
(4) For the postoperative patient, progress notes should record the condition of
the surgical wound, any indication of infection, and the removal of sutures and drains. It
should also record examinations of chest and legs until the patient is ambulatory (walking)
and afebrile (without fever). It also should record the use of casts or splints, and any other
pertinent data.
MD0753 1-13
Figure 1-5. SF 504 (History - Part 1).
MD0753 1-14
MD0753 1-15
MD0753 1-16
Figure 1-8. SF 506 (Physical Examination).
MD0753 1-17
Figure 1-9. SF 509 (Doctor's Progress Notes).
MD0753 1-18
(5) The final progress note should record the patient's general condition upon
discharge and the final diagnosis. In addition, it should prescribe post discharge care
including activity permitted, diet, medications, dressings, and clinic and date for follow-up
care.
(6) In hospital death cases, the final note should describe the terminal
circumstances, findings, and final diagnosis and should state whether or not an autopsy
was performed.
(7) The frequency of progress notes depends on the condition of the patient.
During the acute phase of the illness, the progress notes should be written every day or
even every few hours (very seriously ill/seriously ill patients, at least once a day or more
often). For surgical patients, there must be a daily note for at least the first four
postoperative days. For convalescent patients and fracture patients with no complications,
notes are not needed as often as for patients receiving active treatment. In no case should
more than seven days pass without a progress note.
1-14. DOCTOR'S ORDERS AND NURSING NOTES
a. Use of DA Form 4256. DA Form 4256 (Doctor's Order) is used to convey the
actions the doctor wants for the patient. This form is a three-copy, carbonless form. The
original copy (white) remains with the patient's permanent record. The second copy (pink)
is sent to the pharmacy, where it is kept until the patient is discharged. The ward copy
(yellow) is used to give orders to the nursing staff. Figure 1-10 shows a DA Form 4256
with the doctor's order entered.
(1) Preparation. All entries are made with a ballpoint pen using blue-black or
black ink. The patient identification must be completed in each section using the admitting
plate.
(2) Method of writing orders. More than one order may be written in each
section of the form but not more than one may be written on a single line. The prescriber
must record the date and time each order is written. Each order must be accounted for
separately. All orders must be dated and signed by the doctor.
(3) Method of accounting for orders. Actions taken to comply with written orders
will be accounted for in the far right column of the form entitled "List Time Order Noted and
Sign" column. The nurse or clerk noting the order must list the time orders are noted and
sign or initial his entry. When two or more orders are noted, the nurse may enclose the
orders in a brace, list the time orders noted, and sign or initial his entry.
MD0753 1-19
(4) Use of orders. Every action taken for the patient must be ordered by the
doctor. The doctor uses DA Form 4256 to order laboratory work, medication, diet,
therapy, and so forth. The nurse, technician, or clerk who is responsible must take note of
the orders, enter the time, and either sign or initial in the "List Time Order Noted and Sign"
column of this form.
b. Progress Notes by Nurses. The nurses responsible for the nursing care given
to a patient are required to document this care.
(1) Nurses' notes must chronologically describe the nursing care provided on
SF 510 (Clinical Record--Nursing Notes). (See figure 1-11.)
(2) SF 510 is designed so that the nurse will record the date and time of the
observation. Nurses' observations should include: a description of the patient's condition;
his vital signs; medication administered; treatment provided (when indicated), and any
other pertinent information reflecting the condition of the patient. Each note must be signed
by the nurse, giving rank and corps (if a military nurse) or rank and title (if a civilian nurse).
When the nurse notes an order by the doctor and carries out the order, the nurse must enter
the action on SF 510, including time, action taken, and signature. For example, if the
doctor's order states "Demerol 100 mg IM q 4 hr PRN," the nurse should enter on the
nursing notes "2100, Demerol 100 mg given IM for abdominal pain," and sign the entry,
including rank and corps. The importance of this cannot be overemphasized because if
the nurse fails to enter this data on the nursing notes, no one would know that the patient
had received the medication and another nurse may administer the medication again,
causing an overdose. A drug overdose could compound the patient's illness or result in
death.
MD0753 1-20
Figure 1-10. DA Form 4256 (Doctor's Orders).
MD0753 1-21
Figure 1-11. SF 510 (Nursing Notes).
MD0753 1-22
1-15. DIAGNOSTIC TEST RESULTS (REPORTS)
When a patient is admitted to the hospital, the physician must enter the proposed
diagnostic workup in the Doctor's Progress Notes. The physician orders these tests on
DA Form 4256. The nurse must note the physician's orders for diagnostic tests and enter
the time the patient is sent for the tests in the Nursing Notes. The most common diagnostic
tests include: blood analysis, urinalysis, radiology (X-rays), and electrocardiogram (EKG).
The results of these diagnostic tests must be sent back to the ward for inclusion in the
patient's ITR; the doctor may annotate the results in the Doctor's Progress Notes.
1-16. SPECIAL REQUIREMENTS
If the patient is a surgical or obstetrical patient, additional forms and reports are
required.
a. Surgery or Special Procedures. The forms required for surgery or special

procedures are:
(1) SF 516 (Operation Report). (See figure 1-12.) This report describes the
operation, including the operation performed, the types of sutures used, gross findings, and
other relevant data.
(2) SF 515 (Tissue Examination). (See figure 1-13.) Any time tissue is cut, a
pathological report is required. This form is used to describe the findings of the
pathologist.
(3) SF 522 (Request for Administration of Anesthesia and for Performance of

Operations and Other Procedures). (See figure 1-14.) This form is used as an
authorization or consent form. The patient must sign it to authorize surgery, and the
physician must sign it to indicate that he has counseled the patient about the proposed
procedure.
(4) SF 517 (Anesthesia Form). (See figure 1-15.) This form is used to
describe the administration of anesthesia and to provide a preanesthetic summary.
b. Obstetrical and Newborn.
(1) Two forms are required for the mother when delivering a baby. They are SF
533 (Prenatal Record) and SF 534 (Labor Record).
(2) A newborn baby must have a birth certificate. The birth certificate is a local
form established by the state where the child is born.
MD0753 1-23
Figure 1-12. SF 516 (Operation Report).
MD0753 1-24
Figure 1-13. SF 515 (Tissue Examination).
MD0753 1-25
Figure 1-14. SF 522 (Request for Administration of Anesthesia and for
Performance of Operations and Other Procedures).
MD0753 1-26
Figure 1-15. SF 517 (Anesthesia Form).
MD0753 1-27
1-17. CONCLUSIONS. When the patient is dispositioned, certain forms must be
prepared for inclusion in the Inpatient Treatment Record. They are the:
a. SF 502 (Narrative Summary (NS)). (See figure 1-16.) The Narrative Summary
should be dictated promptly upon disposition of the patient. It is then transcribed on SF
502 (Narrative Summary). The NS should be concise but must include (in narrative form)
the following information:
(1) The reason for hospitalization, including a brief clinical statement of the chief
complaint and history of the present illness.
(2) All significant findings.
(3) All procedures performed and treatment given, including patient's response,
complications, and consultations.
(4) The condition of the patient upon transfer or discharge.
(5) The discharge instructions given to the patient or his family, such as physical
activity permitted, medication, diet, and follow-up care.
(6) All relevant diagnoses made up to the time of discharge or transfer.
b. A discharge note must be entered on SF 509, Doctor's Progress Notes.
c. In an Abbreviated ITR, a discharge note on SF 509 or SF 539 is all that is

required.
MD0753 1-28
Figure 1-16. SF 502 (Narrative Summary).
MD0753 1-29
Section IV. FILING AND DISPOSITION
1-18. FUNCTIONS OF RECORDS
a. Inpatient Treatment Records (ITRs) must provide a written record of the care and
treatment given each patient while hospitalized and must comply with Army regulations and
with standards established by the Joint Commission on Accreditation of Hospital
Organizations (JCAHO).
b. Medical records provide a measure of the quality of care. They are also the
source of documentation for care.
c. Medical records are legal documents. The physician is both legally and morally
responsible for the content of the ITR. The Patient Administration Division has
responsibilities toward these ITRs as well. Ultimate responsibility for ITRs rests with the
MTF Commander.
1-19. SEQUENCE OF FORMS
a. General. AR 40-66 defines the sequence in which the medical forms are filed in
the ITR folder (DA Form 3444-series). Table 1-1 explains the filing sequence for the left
and right sides of the folder.
b. Sequence. The left side of the folder should contain out-of-the-ordinary forms,
such as third party liability notification, very seriously ill/seriously ill reports, and medical
board proceeding. The right side of the ITR folder should contain the more commonly used
forms resulting from hospitalization. Two copies of DA Form 3647 (ITRCS) should be first
in order on the right side; next standard forms (SFs); then, other DA forms; and finally,
DD forms. When more than one copy of a form is used, the forms should be filed
chronologically-- latest date forward.
MD0753 1-30
LEFT SIDE OF FODER
Form Number Form Title and Notes

DA Form 5571 Master Problem List. (Filing in ITR is optional)
DA Form 3947 Medical Evaluation Board Proceedings.
(See AR 40-3).
DA Form 3349 Physical Profile. (See AR-501).
DA Form 3894 Hospital Report of Death. (See AR 40-2).
DA Form 2631-R Medical Care - Third Party Liability Notification.
(See AR 40-16).
DA Form 2984 Very Seriously Ill/Seriously Ill/Special Category
Patient Report. (See AR 40-2).
DA Form 4876-R Request and Release of Medical Information to
Communications Media.
DA Form 5006-R Medical Record - Authorization for Disclosure of
Information.
SF 544 Clinical Record - Statement of Patient's Treatment
DA Form 5009-R Medical Record - Release Against Medical Advice.
RIGHT SIDE OF FOLDER

DA Form 4515 Personnel Reliability Program Record Identifier.
(See AR 50-5).
DA Form 3647 Inpatient Treatment Record Cover Sheet.(all versions).
SF 502 Clinical Record - Narrative Summary.
SF 503 Clinical Record - Autopsy Protocol.
SF 539 Medical Record - Abbreviated Medical Record.
SF 504 Clinical Record - History - Parts II.
SF 505 Clinical Record - History - Parts II and III.
SF 506 Clinical Record - Physical Examination.
SF 535 Clinical Record - Newborn.
SF 509 Medical Record - Doctor's Progress Notes.
SF 558 Medical Record - Emergency Care Treatment.
DA Form 3888 Nursing Care Plan (See AR 40-407).
DA Form 3888-1 Medical Record - Nursing Assessment and Care Plan
Continuation (See AR 40-407).
SF 510 Nursing Notes.
SF 511 Medical Record - Vital Signs Record (See AR 40-407).
SF 512 Clinical Record - Plotting Chart.
Table 1-1. Filing sequence for documents in ITR folder (continued).
MD0753 1-31

SF 513/ Medical Record - Consultation Sheet/Referral for
DD Form 2161 Civilian Medical Care.
SF545 Laboratory Report Display.
SF 515 Medical Record - Tissue Examination.
SF 516 Medical Record - Operation Report.
SF 517 Clinical Record - Anesthesia.
SF 518 Medical Record - Blood or Blood Component Transfusion.
SF 519B Radiologic Consultation Request/Report.
SF 520 Clinical Record - Electrocardiographic Record.
SF 522 Medical Record - Request for Administration of
Anesthesia and for Performance of Operations and
Other Procedures (See AR 40-3).
SF 523 Clinical Record – Authorization for Autopsy.
SF 523A Medical Record - Disposition of Body.
SF 523B Medical Record - Authorization for Tissue Donation.
SF 524 Medical Record - Radiation Therapy.
SF 525 Medical Record - Radiation Therapy Summary.
SF 526 Medical Record - Interstitial Intercavitary Therapy
SF 527 Medical Record - Group Muscle Strength, Joint
R.O.M. Girth and Length Measurements.
SF 528 Medical Record - Muscle Function by Nerve
Distribution: Face, Neck, and Upper Extremity.
SF 529 Medical Record - Muscle Function by Nerve
Distribution: Trunk and Lower Extremity.
SF 530 Clinical Record - Neurological Examination.
SF 531 Medical Record - Anatomical Figure.
SF 533 Medical Record - Prenatal and Pregnance (and
relate prenatal documents).
SF 534 Medical Record - Labor.
SF 536 Clinical Record - Pediatric Nursing Notes.
SF 537 Medical Record - Pediatric Graphic Chart.
SF 538 Clinical Record – Pediatric.
SF 541 Medical Record - Gynecological Cytology.
SF 560 Medical Record - Electroencephalogram Request and History.
Table 1-1. Filing sequence for documents in ITR folder (continued).
MD0753 1-32

DA Form 3824 Urologic Examination.
DA Form 4221 Diabetic Record.
DA Form 4221 Diabetic Record.
DA Form 4256 Doctor's Orders.
DA Form 4677 Therapeutic Documentation Care Plan (Non-Medication
(See AR 40-407).
DA Form 4678 Therapeutic Documentation Care Plan
(Medication) (See AR 40-407).
DA Form 4700 Medical Record - Supplemental Medical Data.
DA Form 5128 Clinical Record - Visual Field Examination.
DD Form 602 Patient Evacuation Tag (See AR 40-40).
DD Form 741 Eye Consultation.
DD Form 749 Clinical Record - Head Injury (for file purpose only).
DD Form 1380 U.S. Field Medical Card.
DA Form 4359-R Authorization for Psychiatric Service. Treatment (See AR 40-3).
Medical Reports on a stillborn infant. (Filed in the mother's ITR.)
DA Form 2985 Admission and Coding Information.
DA Form 4410-R Disclosure Accounting Record. To be included when preprinted
DA Form 3444 series folders are not used.
DD Form 2005 Privacy Act Statement - Health Care Records. To be included
when preprinted DA Form 3444 series folders are not used
Table 1-1. Filing sequence for documents in ITR folder (concluded).
1-20. DISPOSITION OF RECORDS
a. Termination of Treatment. When the patient is discharged from the hospital at

the end of treatment, the ITR must be completed before filing.
(1) Attending physician. The attending physician completes the worksheet copy
of the ITRCS. The attending physician dictates the Narrative Summary and makes final
progress notes on SF 509 or SF 539. When this is accomplished, the physician forwards
the ITR to the Patient Administration Division.
MD0753 1-33
(2) Patient Administration Division (PAD). The personnel in PAD must code
and complete the ITRCS in typewritten form. (Both the worksheet and the typewritten copy
of the ITRCS should be filed in the ITR.) Then, forms must be assembled in the order
described in table 1-1 and fastened into the ITR folder. The record must be reviewed for
accuracy; completeness, including dates and signatures; laboratory reports; X-ray reports;
and other reports, as necessary. If errors are found or if information or signatures are
missing, the record must be sent to the physician or nurse, as appropriate, for correction
and completion. Once the record is complete, the ITR must be filed as described in the
lesson "Terminal Digit Filing" in Subcourse MD0751.
b. Transfer for Further Treatment in Military MTF or Veterans Administration

(VA) MTF. Occasionally, patients are transferred to another uniformed service or VA
medical treatment facility (MTF). When this happens, certain actions on the ITR are
required by the physician and PAD.
(1) Attending physician. The physician completes the worksheet copy of the
ITRCS, dictates or writes up the SF 502 (Narrative Summary), and forwards the ITR to the
PAD.
(2) Patient Administration Division. PAD personnel must complete the ITRCS
in typewritten form; assemble and review the entire record for accuracy and completeness;
make copies of the ITRCS and Narrative Summary; and forward the ITR with the patient to
the next uniformed service or Veteran's Administration MTF. The movement of the patient
must not be delayed for completion of his record. Medical care has first priority;
administrative needs are secondary.
c. Discharge for Movement to Civilian MTF. At times, a patient may be sent to

a civilian hospital for treatment when it is not available at the military MTF. In this case, the
original ITR must remain with the Army MTF since this record is the property of the U.S.
Government. When a patient is sent to a civilian hospital for treatment, these actions must
be taken:
(1) The doctor and PAD personnel process the ITR in the same manner as a
termination for treatment (discussed in paragraph 1-20a).
(2) A copy of the ITR is prepared and sent with the patient to the civilian facility.
(3) The original ITR is retained and filed according to the standard procedure.
d. Retirement of Records for Storage. The rules for retirement of records

depend upon the status of the military treatment facility. AR 40-66 specifies that medical
centers (MEDCENS) are to have five-year inpatient treatment record maintenance. These
medical centers are: Brooke Army Medical Center, Fitzsimons Army Medical Center,
Madigan Army Medical Center, Tripler Army Medical Center, William Beaumont Army
Medical Center, Walter Reed Army Medical Center, Dwight David Eisenhower Army
MD0753 1-34
Medical Center and Womack Army Medical Center. MEDCENs are usually teaching
hospitals.
(1) Teaching hospitals. A teaching hospital provides advanced training such as

the training of interns and residents. In a MEDCEN or teaching hospital, Inpatient
Treatment Records are maintained five years after the year of disposition (the treatment
year). ITRs are:
(a) Held for five years after the year of disposition.
(b) Retired after the five-year holding period.
Example:
Treatment Year = 1993

Holding Years = 1994, 1995, 1996,1997, 1998
Date of Retirement = January 1999
(2) Nonteaching hospitals. Medical treatment facilities having no official training

program are classified as nonteaching hospitals. In a nonteaching hospital, ITRs are:
(a) Held for one full year after the year of disposition (the treatment year).
(b) Retired after the one-year holding period (unless the patient has been
readmitted).
Example:
Treatment Year = 1993

Holding Year = 1994
Date of Retirement = 1995
e. Retrieval of Records from Storage.
(1) When medical records (to include ITRs) are retired, they are sent to a
repository (storage area) in St. Louis, Missouri.
(2) To retrieve retired records from the repository, a physician must advise PAD
of the need for the record. PAD, in turn, must send a written request to St. Louis. After the
record is no longer needed, it is returned to the repository in St. Louis. If required
indefinitely, the record may be retained; however, written notification must be sent to the
repository.
MD0753 1-35
f. Access and Audit Trail. Access must be given to ITRs on file or to cases
having register numbers. In addition, a record audit trail must be kept. Two indexes will be
kept for this purpose, the nominal index and the register number index.
(1) Nominal index. The nominal index will include a card for each patient
assigned a register number. Each card will list the patient's name, SSN with FMP, and
register number. The cards will be filed alphabetically by last name. If the patient is
transferred, the date of transfer and the name of the receiving MTF will be noted on the
card. A manual nominal index is not required for those MTFs using AQCESS (Automated
Quality of Care Evaluation Support System), CHCS (Composite Health Care System), or
other automated patient data systems.
(2) Register number index. A MEDCEN does not need to maintain this index,
because the ITRs are maintained for 5 years. A MEDDAC (Medical Department Activity)
will maintain a register number index for 5 years. The register number index will include a
copy of DA Form 3647 for each patient assigned a register number. A copy of SF 502
(when prepared) may be attached to the DA Form 3647. This index will be kept in register
number sequence. For transfer cases, a copy of the transmittal form will be attached to
DA Form 3647.
Continue with Exercises
MD0753 1-36
EXERCISES, LESSON 1
INSTRUCTIONS: Answer the following exercises by marking the lettered response that
best answers the exercise, by completing the statement, or by writing the answer in the
space provided at the end of the exercise.
After you have completed all the exercises, turn to "Solutions to Exercises" at the end
of the lesson and check your answers with the solutions.
For exercise 1 through 7, place one of the codes listed below in the blank
after each statement to indicate the type of inpatient treatment record that
should be initiated:
a = Routine ITR
b = Abbreviated ITR
c = CRO ITR
d = No ITR
1. An infant is born dead. ___
2. The patient is hospitalized four days with a bleeding ulcer. ___
3. The patient enters the hospital for heart surgery. ___
4. A patient breaks his arm and remains in the hospital overnight. ___
5. The patient is hospitalized overnight for a tonsillectomy (minor surgery). ___
6. The patient is DOA at the hospital from a drug overdose. ___
7. A rape victim is examined and treated. ___
8. The forms and reports filed in an ITR depend on ________________________
MD0753 1-37
9. Why is the use of a rubber block stamp under the signature on ITRs
recommended?
________________________________________.
10. List the three requirements of the physical examination for the inpatient.
a. ______________________________.
b. ______________________________.
c. ______________________________.
11. List the minimum requirements of patient identification on an ITR.
________________________________________________________________
12. The Narrative Summary is prepared upon disposition of the patient. What must
be included in the Narrative Summary?
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
13. List the functions of medical records.
______________________________
______________________________
______________________________
______________________________
MD0753 1-38
14. When a patient is discharged upon termination of treatment, the attending
physician is required to complete the ITR before forwarding it to the PAD. List the three
things the physician must do to complete the ITR.
a. ______________________________
b. ______________________________
c. ______________________________
15. What action should be taken when PAD personnel review the ITR and find
information or a signature is missing?
________________________________________________________________
16. Define a teaching hospital.
________________________________________________________________
Check Your Answers on Next Page
MD0753 1-39
SOLUTIONS TO EXERCISES, LESSON 1
1. d. (para 1-4b)
2. a. (para 1-6a)
3. a. (para 1-6c)
4. b. (para 1-7a)
5. b. (para 1-7a)
6. c. (para 1-8a)
7. c. (para 1-8c)
8. The nature of the case and treatment given. (para 1-9a)
9. To identify the person making the entry. (para 1-10c)
10. a. The physical examination must be current (must have been completed within
the 24 hours period preceding the examination).
b. The physical examination must be related to the illness for which the patient is
hospitalized.
c. Findings must be recorded in specific terms. (para 1-12b)
11. Patient's name, rank, grade or status, family member prefix, sponsor's SSN, and
register number (para 1-11a)
12. Reason for hospitalization.

All significant findings.
All procedures performed and treatment given.
Condition of patient at time of transfer or discharge.
Discharge instructions.
All relevant diagnosis. (para 1-17a)
13. To provide a written record of the treatment and care of each patient when he is
hospitalized.
To demonstrate compliance with Army regulations and JCAHO standards.
To provide a measure of the quality of patient care.
To provide legal documentation of patient care. (para 1-18)
14. a. Complete the ITRCS worksheet.

b. Dictate the Narrative Summary.
c. Make final progress notes. (para 1-20a(1))
MD0753 1-40
15. The ITR must be returned to the physician or nurse for completion.
(para 1-20a(2)
16. One in which official training is provided. (para 1-20d(1))
END OF LESSON 1
MD0753 1-41
LESSON ASSIGNMENT
LESSON 2 Diagnostic and Operative Coding.
2-1. Properly code the diagnoses, operations, and

procedures provided in the lesson exercise,
through the use of the ICD-9-CM.
2-2. Identify the general characteristics of the

ICD-9-CM Tabular List, Alphabetical Index, and
the Procedures Classification Manual Book.
SUGGESTION After completing the assignment, complete the

exercises of this lesson. These exercises will help
MD0753 2-1
LESSON 2
DIAGNOSTIC AND OPERATIVE CODING
Section I. GENERAL
2-1. INTRODUCTION
Statistical information is used for research, training, manpower requirements,

budget requirements, and future planning for the medical community. One of the
elements of statistical information is the numerical classification of diseases, injuries,
and operative procedures. Medical terminology does not blend into the computerized
statistical reports required by the Army, so a numerical classification is used. You may
recall from the lesson you had in admission and disposition procedures the use of the
ICD-9-CM code number on the imprinting plate which was initiated at the time of
admission. In this lesson, you will learn the process of coding diseases, injuries, and
operative procedures and put that knowledge to practical use in your work in the Patient
Administration Division (PAD).
2-2. CLASSIFICATION OF DISEASES AND PROCEDURES
a. The resource used in the classification of diseases and medical procedures is

the International Classification of Diseases-9th Revision Clinical Modification
(ICD-9-CM). The ICD-9-CM consists of three volumes which are based on the
International Classification of Diseases, 9th Revision (ICD-9) published by the World
Health Organization. These references provide for classification of morbidity and
mortality information for statistical purposes and for indexing of hospital records by
disease and by medical operation to facilitate data storage and retrieval.
b. History and Development of the ICD-9-CM. In February 1977, a steering

committee was convened by the National Center for Health Statistics to provide advice
and counsel to the development of a clinical modification of the International
Classification of Diseases, 9th Revision. As a result of this steering committee's efforts,
the ICD-9-CM was published in 1979. The second edition that you are using is probably
dated September 1980. The term "clinical" is used to emphasize the modification's
intent; to serve as a useful tool in the area of classification of morbidity data for indexing
of medical records, medical care review, ambulatory and other medical care programs,
as well as for basic health statistics. To describe the clinical picture of the patient, the
codes must be more precise than those needed only for statistical grouping and trend
analysis.
c. The ICD-9-CM is totally compatible with its parent system, the ICD-9, thus
meeting the need for comparability of morbidity and mortality statistics at the
international level.
MD0753 2-2
2-3. GENERAL CHARACTERISTICS OF THE ICD-9-CM, TABULAR LIST (VOL I)
a. Volume I, The Tabular List. This volume of the ICD-9-CM is arranged in

seventeen major sections, each covering a category of diseases (see figure 2-1). The
first category covers diseases caused by well-defined infective agents. The subsequent
categories cover: neoplasms; endocrine; nutritional, and metabolic diseases. Most of
the remaining diseases are arranged according to their principal anatomical site. There
are special sections for mental diseases, complications of pregnancy and childbirth,
certain diseases peculiar to the perinatal period, and ill-defined conditions including
symptoms.
b. A decimal system of numbering has been adopted in which the detailed

categories of the classification are designated by three-digit numbers. In many
instances, the first two digits of the three-digit number designate important or summary
groups of significance. The third digit divides each group into categories which
represent specific disease entities or a classification of the disease or condition
according to some significant axis, such as anatomical site.
(1) The fourth-digit subcategories provide further specificity or additional

information about the etiology or manifestations of the disease. Also, when appropriate
and possible to include residual subcategories for "other" and "unspecified," these have
been numbered consecutively 8 and 9, respectively.
(2) Optional fifth digits are provided in certain places; for example, for the
mode of diagnosis in tuberculosis and for anatomical site in musculoskeletal disorders.
2-4. GENERAL CHARACTERISTICS OF THE ICD-9-CM, DISEASES

(ALPHABETICAL) INDEX (VOL 2)
a. Volume 2 of the ICD-9-CM is referred to as an Alphabetical Index. This index

is used in conjunction with the Tabular List of Volume 1. In coding, you should always
refer to the Tabular List and its notes to ensure that the code given by the index fits the
circumstances of a particular case.
b. The ICD-9-CM Alphabetical Index is an essential adjunct to the Tabular List; it

contains a great number of diagnostic terms which do not appear in Volume 1. The
terms included in a category of the Tabular List do not make up an exhaustive list of
terms. Rather, the terms provide examples of the content of the category. The
Alphabetical Index, on the other hand, is intended to include all diagnostic terms
currently in use.
c. Because of its exhaustive nature, the Alphabetical Index inevitably includes

many imprecise and undesirable terms. Since these terms are still occasionally
encountered on medical records, coders need an indication of their assignment in the
classification, even if this is to a rubric (title) for residual or ill-defined conditions.
MD0753 2-3
TABLE OF CONTENTS
FOREWARD iii
PREFACE v
ACKNOWLEDGMENTS vii
INTRODUCTION xv
CONVENTIONS USED IN THE TABULAR LIST xxiii
GUIDANCE IN THE USE OF ICD-9-CM xxv
CLASSIFICATION OF DISEASES AND INJURIES
1. Infectious and Parasitic Diseases 1

2. Neoplasms 81
3. Endocrine, Nutritional and Metabolic Diseases, and 154
Immunity Disorders
4. Diseases of the Nervous System and Sense Organs 188
5. Mental Disorders 204
6. Diseases of the Nervous System and Sense Organs 251
7. Diseases of the Circulatory System 358
8. Diseases of the Respiratory System 404
9. Diseases of the Digestive System 432
10. Diseases of the Genitourinary System 481
11. Complications of Pregnancy, Childbirth, and 527
the Puerperium
12. Diseases of the Skin and Subcutaneous Tissues 569
13. Diseases of the Musculoskeletal System and 593
Connective Tissue
14. Congenital Anomalies 639
15. Certain Conditions Originating in the Perinatal Period 683
16. Symptoms, Signs, and Ill-Defined Conditions 707

17. Injury and Poisoning 735
SUPPLEMENTARY CLASSIFICATION
Classification of Factors Influencing Health Status and 880

Contact with Health Service
Classification of External Causes of Injury and Poisoning 930
APPENDICES
A. Morphology of Neoplasms 1055
B. Glossary of Mental Disorders 1077
Figure 2-1. Volume 1, Table of Contents. (Continued)
MD0753 2-4
C. Classification of Drugs by American Hospital 1127
Formulary Service List Number and Their
ICD-9-CM Equivalents
D. Classification of Industrial Accidents According 1137
to Agency
E. List of Three Digit Categories 1143
Figure 2-1. Volume 1, Table of Contents. (Concluded)
The presence of a term in this volume, therefore, should not be taken as sanction for its
usage in good medical terminology.
2-5. GENERAL CHARACTERISTICS OF THE ICD-9-CM, PROCEDURES MANUAL

(VOLUME 3)
a. The structure of the Procedures Manual is similar to that of the Volumes 1 and
2. Volume 3 contains a tabular list and an alphabetical index.
b. The complete series of categories for the 16 chapters of the Volume 3 are
numbered from 010 to 9999. The classification is significant at the three-digit level; the
fourth-digit provides for greater detail and precision.
2-6. CODING PRINCIPLES
a. Certain diagnoses are coded according to specific rules. Appendix A of this

lesson contains excerpts, (modified for instructional purposes) taken from the Individual
Patient Data System (IPDS) User's Manual of the U.S. Army Medical Command, U.S.
Army Patient Administration Systems and Biostatistics Activity. The excerpts provide
coding principles to be used in diagnostic and operation coding.
b. The IPDS User's Manual includes more principles than are included in this
lesson. Principles discussed in this lesson have the same number as the principles in
the User's Manual. This will enable you to identify the principles omitted from this
lesson.
c. Since the actual ICD-9-CM, Volumes 1, 2, and 3 cannot be provided, the

following data is provided to indicate where the pages cited in this lesson may be found
in the directive:
(1) See Appendix B for "Excerpts from Volume 1, ICD-9-CM."
(2) See Appendix C for "Excerpts from Volume 2, ICD-9-CM."
(3) See Appendix D for "Excerpts from Volume 3, ICD-9-CM."
MD0753 2-5
Section II. CONVENTIONS AND TERMINOLOGY
2-7. GENERAL
The following paragraphs explain (and provide examples of) the signs, symbols,
abbreviations, and instructions you will encounter in using the ICD-9-CM. Most of this
information can also be found in the IPDS User's Manual.
2-8. INSTRUCTIONAL TERMS
a. Inclusion Terms. These are secondary terms which indicate that the code
and title embrace these terms. Inclusion terms are not to be taken as all-inclusive, but
rather as an example of the terms included.
030 Leprosy
Includes: Hansen's disease

infection by Mycobacterium leprae
b. Exclusion Terms. These are secondary terms indicating that the

conditions/procedures are not included but may be found elsewhere. Exclusion terms
are always written in italics and the word excludes is written in italics and in a box.
EXAMPLE: 117.6 Allescheriosis [Petriellidosis]

Infections by Allescheria [Petriellidium] boydii
[Monosporium apiospermum]
Excludes: mycotic mycetoma (117.4)
c. NOTE. Found throughout the ICD-9-CM manuals (all volumes), and directs
the coder toward specific classification assignments.
EXAMPLE: Choledocholithiasis 574.5
Note--Use the following fifth-digit

subclassification with category 574:
0 without mention of obstruction
1 with obstruction
with cholecystitis (chronic) 574.4

acute 574.3
MD0753 2-6
d. See. Refers the coder to another diagnosis. The code will not be given at the
first point. This makes it absolutely necessary that the coder refer to an additional term.
EXAMPLE: Hardening
artery — see Arteriosclerosis
brain 348.8
liver 571.8
e. See category. Refers the coder to Volume 1. This pertains to three-digit

classifications. For most accurate coding, this step is essential.
EXAMPLE: Fever — continued

cerebral 323.9
late effect — see category 326
f. See also. Refers coder to another diagnosis (usually placed in parentheses),

and a code number will be provided in both places. Occasionally, the code will differ.
EXAMPLE: Apophysitis (bone) see also

Osteochondrosis) 732.9
calcaneus 732.5
juvenile 732.6
g. Omit code. Used primarily in Volume 3 when the procedure is the method of
approach for an operation.
EXAMPLE:
Laparotomy NEC 54.19

as operative approach -- omit code
exploratory (pelvic) 54.11
reopening of recent operative site (for

control of hemorrhage) (for
exploration) (for incision of
hematoma) 54.12
NOTE: If a laparotomy incision was made for abdominal surgery, the code for
laparotomy would not be used.
MD0753 2-7
h. Code also. Used when more than one code is necessary to fully identify a
given condition or procedure. Code also is used in Volume 1 and Volume 3 to code the
cause of the condition (etiology) or each component of the procedure.
EXAMPLE: Volume 1
774.5 Perinatal jaundice from other causes
Code also underlying cause, as:

congenital obstruction of bile duct (751.61)
galactosemia (271.1)
mucoviscidosis (277.00-277.01)
EXAMPLE: Volume 3
42.42 Total esophagectomy

Code also any synchronous:
gastrostomy (43.1-43.2)
interposition or anastomosis other than
end-to-end (42.51-42.69)
Excludes: esophagogastrectomy (43.99)
i. Use additional code. Appears only in Volume 1. More than one code is used
to more accurately describe the diagnosis. When coding in a military MTF disregard "if
desired" and assign the additional code.
EXAMPLE:
491 Chronic bronchitis

Use additional code, if desired, to
identify acute exacerbation (466.0-466.1)
MD0753 2-8
2-9. PUNCTUATION MARKS
a. Parentheses ( ( ) ). Used to enclose supplementary words that may or may

not be stated as part of the physician's diagnosis/ procedure, and that do not change
the appropriate code.
EXAMPLE:
Hypophosphatemia (acquired) (congenital)

(familial) 275.3
renal 275.3
b. Square brackets ( [ ] ). Used to enclose synonyms, alternate wording, or

explanatory phrases or reference assignable 5th digit specificity. Square brackets are
also used to give you an additional code that is needed code.
EXAMPLE: 50.1 Diagnostic procedures on liver
50.11 Percutaneous [needle] biopsy of liver

Diagnostic aspiration of liver
c. Colons (:). Indicates an incomplete term or phrase that must have one of the
modifiers (which follow) in order to make it assignable to the specific category.
EXAMPLE: 491.1 Mucopurulent chronic bronchitis

Bronchitis (chronic) (recurrent):
fetid
mucopurulent
d. Braces ( } ). Used to connect a series of words to a common term.
EXAMPLE: 250.1 Diabetes with ketoacidosis;

Diabetic:
adidosis
ketosis } without mention of coma
MD0753 2-9
2-10. ABBREVIATIONS
a. Not elsewhere classifiable (NEC). Added after terms classified in

unspecified categories and to terms in themselves ill-defined. The category number for
the term including NEC is to be used only when the coder lacks the information
necessary to code the term to a more specific category. If the medical record includes
more precise information, the coding should be modified accordingly. NEC is used in
the Alphabetical Indexes Volume 2 and Volume 3.
EXAMPLES: Aborter, habitual or recurrent NEC

without current pregnancy 629.9
current abortion (See also Abortion,
spontaneous) 634.9
affecting fetus or newborn 761.8
observation in current pregnance 646.3
Lavage
antral 22.00
bronchus NEC 96.56
endotracheal 96.56
gastric 96.33
b. Not otherwise specified (NOS). Is equivalent to "unspecified." NOS is used

in the Tabular Lists (Volume 1 and Volume 3).
EXAMPLES: 250.0 Diabetes mellitus without mention of

complication
Diabetes mellitus without mention of
complication or manifestation
classifiable to 250.1-250.9
Diabetes (mellitus) NOS
16.49 Other enucleation of eyeball

Removal of eyeball NOS
2-11. SYMBOLS
a. Lozenge ( ¨ ). Found only in Diseases Tabular List (Volume 1). The

lozenge is printed in the left margin preceding the disease code. It denotes a four-digit
rubric (title) unique to ICD-9-CM. The lozenge has no effect on coding, it is used for
comparison studies with ICD-9.
EXAMPLE: 250.2 Diabetes with hyperosmolar coma

Hyperosmolar (nonketotic) coma
MD0753 2-10
b. Section mark ( § ). Denotes a footnote at the bottom of the page and is
applicable to all subdivisions within that code. The section mark may refer to
requirement of a fifth digit.
EXAMPLE: §38.4 Resection of vessel with replacement
[0-9] Angiectomy
Excision of:
Aneurysm (arteriovenous) with replacement
Blood vessel (lesion)
Requires fourth digit; valid digits are in [brackets] under each code. See page 99 for definitions.
2-12. RELATED TERMS
a. See condition. Refers the coder to the term identifying the specific disease
or injury of the patient. This instruction is most frequently seen when the coder looks for
the body part as the main term instead of the specific disease or injury (i.e., deformity of
the hand). If the coder looks under the main term hand, it will read "see condition."
Deformity is the condition.
EXAMPLE: Hand — see condition
b. And. Indicates involvement of either or both terms/sites.
EXAMPLE: 31 Other operations on larynx and trachea
31.0 Injection of larynx

Injection of inert material into larynx or
vocal cords
c. With. Indicates that both terms must be present and part of the diagnoses or
procedure stated by the physician.
EXAMPLE: § 38.1 Endarterectomy

[0-6.8] Endarterectomy with:
embolectomy
patch graft
temporary bypass during procedure
thrombectomy
MD0753 2-11
Section III. USE OF ICD-9-CM
2-13. GENERAL
a. In the ICD-9-CM, the tabular list is in Volume 1 and the alphabetical index is in
Volume 2. Having the alphabetical index in a separate volume eliminates turning pages
back and forth and makes it easier to verify codes in Volume 1. Volume 3, the
procedures manual, contains both the tabular list and alphabetical index. The
alphabetical index is located at the back of Volume 3.
b. As explained in lesson 1, each ITR must have two copies of an ITRCS: a

handwritten physician's work copy and a typewritten copy. The physician writes the
diagnoses and any procedures the patient undergoes on the work copy of the ITRCS.
When the work copy is received in the Patient Administration Division, you locate the
diagnostic or procedural codes in the ICD-9-CM. These codes are entered on the
typewritten copy (see figure 2-2).
c. Since medical nomenclatures (names) may be obtained from laboratory

reports, radiological reports, consultations, and other sources where information is
recorded by approved and authorized clinicians, medical officers, and dental officers,
the patient administration specialist must check the clinical record thoroughly for any
nomenclature or qualifying terms that may have been overlooked. Although the
ICD-9-CM set of volumes is not provided to physicians for their use as guides in
expressing diagnoses, physicians are not precluded from using them to assist medical
records personnel in the proper coding of diseases and surgical procedures.
d. The nomenclature of a diagnosis or procedure must be as explicit and

complete as possible. In addition to the name of the disease or pathological condition,
body parts or anatomical sites must be given, when relevant, and terms such as "right,"
"left," "bilateral," "posterior," and "anterior" must be included, when applicable.
e. In coding diseases and injuries, you should locate the diagnoses in the
Alphabetical Index, Volume 2, then verify the diagnoses in the Tabular List, Volume 1.
Close attention to any notes or directions found in Volume 1 is necessary for accurate
coding. Since you must begin the coding process with the Alphabetical Index of Volume
2, it will be covered first.
2-14. ARRANGEMENT OF THE ALPHABETICAL INDEX
a. The Alphabetical Index is divided into three sections.
(1) Section I, "Alphabetical Index to Diseases and Injuries." This section

contains an alphabetical index of diseases, injuries, and other conditions, except
poisoning or other adverse effects of drugs and other chemical substances.
MD0753 2-12
Figure 2-2. ITRCS (handwritten and typed copies) (continued).
MD0753 2-13
Figure 2-2. ITRCS (handwritten and typed copies) (concluded).
MD0753 2-14
(2) Section II, "Table of Drugs and Chemicals ." This section is not used by
the Army. Instead, Appendix C of the Individual Patient Data System (IPDS) User's
Manual is used. This User's Manual is a publication of the U.S. Army Medical
Department Center and School, Directorate of Patient Administration Systems and
Biostatistics.
(3) Section III, "Alphabetical Index to External Causes of Injuries and

Poisonings." These terms are not medical diagnoses, but describe the circumstances
under which an accident or act of violence occurred (i.e., the underlying cause or means
of injury). Use of this section by the Army is limited. It will be discussed later in this
lesson.
b. As mentioned earlier, Volume 2 is arranged alphabetically (see figure 2-3). In

first order are the main terms (names or nomenclatures of diagnoses). Next, are the
modifiers of the main terms. Main terms are printed in bold face type. Modifiers are
indented under the main terms. As you see in the example below, each level of
indentation modifies or relates to the level above it. The arrangement is similar to that
of an outline.
(1) Modifiers indented 2 spaces modify or relate to the main term.
(2) Modifiers indented 4 spaces modify or relate to the nearest 2 space

indentation.
(3) Modifiers indented 6 spaces modify or relate to the nearest 4 space

indentation.
(4) The same principle applies regardless of the number of levels of

indentation under a main term.
EXAMPLE: Aphthae, aphthous — see also condition

Bednar's 528.2
cachectic 529.0
epizootic 078.4
fever 078.4
oral 528.2
stomatis 528.2
thrush 112.0
ulcer (oral) (recurrent) 528.2
genital organ(s) NEC
female 629.8
male 608.89
MD0753 2-15
Figure 2-3. Example of alphabetic arrangement of Volume 2, ICD-9-CM (showing
indentation of main terms and modifiers).
MD0753 2-16
2-15. STEPS IN USING VOLUME 2
Here are the steps for using Volume 2, ICD-9-CM recommended by the IPDS
User's Manual:
a. Locate the condition (main term) in the Alphabetical Index. The main term is
printed in bold face type for ease of reference. Main terms will identify disease
conditions (Aphthae, aphthous) or state the actual problem (Infarction). A main term
may be followed by a series of terms in parentheses and may also be followed by a list
of subterms (modifiers) which are indented two spaces. A main term can never be a
body part or organ such as heart, artery, or stomach. Be sure to start at the main term.
b. Look for eponyms (diseases or operations named after a person, e.g.,

Parkinson's disease) under the person's name or under the main terms "Disease" or
"Syndrome" or "Tremor."
c. Look for conditions expressed as adjectives (e.g., irregular) in the list of main
terms.
d. Be sure to read and follow any "NOTE" listed under the main term. A note is
usually found at the beginning of a main term, but is not repeated on continuing pages.
e. Read terms enclosed in the parentheses following the main term and
modifiers.
f. Be guided by the "see" and "see also" in cross-referencing synonyms and

closely related terms. Remember that "see condition" usually indicates that you have
located the body part in the index rather than the disease or injury of that part.
g. Use E-codes (E930-E949) to identify adverse effects of drugs and chemicals

properly administered. The Army uses only E-codes under the heading "Adverse Effect
In Correct Usage." These E-codes will require a "Cause of Injury" code from the IPDS
User's Manual. This is discussed in greater detail later in this lesson.
h. Use V-codes (V01-V82) when a person who is not currently ill is hospitalized
for some specific purpose such as birth, observation, or to donate an organ. When
some circumstance or problem is present which influences the person's health status
but is not in itself the cause of admission, V-codes are used as supplementary codes.
i. The Hypertension Table is found under the main term "Hypertension." This
table contains a complete listing of all conditions due to or associated with hypertension
and classifies them according to malignant (life-threatening), benign (not life-
threatening), and unspecified condition.
j. Neoplasms are listed in the Alphabetic Index in two ways: anatomic site and
morphology (structure of the organ or part). Morphology codes may be used at the local
MD0753 2-17
level by the Tumor Registry in military services facilities. The comprehensive list by
anatomic sites is found in a Neoplasm Table under the main term "Neoplasm,
neoplastic." The table contains six columns: primary, secondary, and in situ if
diagnosed as malignant and benign, uncertain behavior, or unspecified.
2-16. ARRANGEMENT OF THE TABULAR LIST
a. As explained earlier, the Tabular List, Volume 1, is arranged in 17 main

sections (see figure 2-1) which are in numerical order by three-digit numbers. The first
two digits indicate important or summary groups (e.g., 01 Tuberculosis, 40 Hypertensive
Heart Disease). The third-digit divides each group into categories representing specific
disease entities or the classification of the disease or condition, such as anatomical site
(e.g., 810 Fracture of Clavicle, 812 Fracture of Humerus).
b. There are also fourth-digit numbers which appear after a decimal. (Military
services facilities disregard the decimal.) The fourth-digit provides more information
about the disease or condition (e.g., 157.1 Body of pancreas, 157.2 Tail of pancreas).
EXAMPLE: 157 Malignant neoplasm of pancreas
157.0 Head of pancreas
157.1 Body of pancreas
157.2 Tail of pancreas
157.3 Pancreatic duct
c. In some places, "optional" fifth-digit classifications are provided for even more
specificity (e.g., 715.01 Osteoarthrosis, generalized of the shoulder region, 714.02
Osteoarthrosis, generalized of the upper arm). Such classifications are usually at the
beginning of a chapter or at the beginning of a three-digit category. Although ICD-9-CM
states that these are optional, the Army requires that these classifications be used.
a. Verify that the code number selected from the Alphabetical Index (Volume 2)
is appropriate with the correct diagnostic classification.
b. Read all inclusions, exclusions, and notes under the selected code.
Remember that these may be at the beginning of a chapter or a three-digit category.
c. Disregard decimal points appearing in ICD-9-CM when coding a disease or

cause of injury diagnosis.
MD0753 2-18
d. Use secondary codes if indicated by "Use additional code, if desired. . ." The
Army requires the use of secondary codes.
e. Use fifth-digit codes in ICD-9-CM, Volume 1 to identify manifestations of

diseases.
f. Use DOD extender codes as provided in Appendix A of the Triservice Disease

and Procedures Coding Guidelines (ICD-9-CM), dated 1 January 1991. (See Coding
Principles in Appendix A of this subcourse.)
g. Verify the code at the main 3-digit category for any added instructions.
2-18. ARRANGEMENT OF THE PROCEDURES CLASSIFICATION
Volume 3 is the Procedures Classification book. Volume 3 contains two major

subdivisions : the Tabular List of Procedures and the Alphabetic Index to Procedures.
TABLE OF CONTENTS
FOREWARD iii
PREFACE v
ACKNOWLEDGMENTS vii
INTRODUCTION xv
CONVENTIONS USED IN THE TABULAR LIST xxiii
CONVENTIONS USED IN THE ALPHABETIC INDEX xxv
Tabular List
1. Operations on the Nervous System 1

2. Operations on the Endocrine System 15
3. Operations on the Eye 22
4. Operations on the Ear 46
5. Operations on the Nose, Mouth, and Pharynx 53
6. Operations on the Respiratory System 71
7. Operations on the Cardiovascular System 83
8. Operations on the Hemic and Lymphatic System 110
9. Operations on the Digestive System 114
10. Operations on the Urinary System 155
11. Operations on the Male Genital Organs 172
12. Operations on the Female Genital Organs 181
13. Obstetrical Procedures 198
14. Operations on the Musculoskeletal System 205
15. Operations on the Integumentary System 238
16. Miscellaneous Diagnostic and Therapeutic Procedures 248
Alphabetic Index 301
Figure 2-4. Volume 3, Table of Contents.
MD0753 2-19
a. The Tabular List. The structure of classification is based on anatomy rather
than surgical specialty (see figure 2-4). There are 16 chapters in the Tabular List. The
first 15 chapters refer to the anatomical systems, whereas chapter 16 refers to
miscellaneous diagnostic and therapeutic procedures.
(1) The procedure code is based on a two-digit section code with two decimal
digits where necessary (the Army disregards the decimal). The two-digit section code
provides a heading by site and general description of the procedure. The three-digit
category code specifies the procedure. The four-digit subcategory code provides
greater specificity in identifying anatomical sites and defining selected procedures,
techniques, or the surgical approach.
(2) All surgical or procedure codes will contain three or four-digits. Do not
zero-fill to the right for three-digit codes.
EXAMPLE:
30 Excision of larynx
30.0 Excision or destruction of lesion or tissue

of larynx
30.01 Marsupialization of laryngeal cyst
30.09 Other excision or destruction of

lesion or tissue of larynx
Stripping of vocal cords
Excludes biopsy of larynx (31.43)

laryngeal
fistulectomy (31.62)
laryngotracheal
fistulectomy (31.62)
b. The Alphabetic Index to Procedures. This index follows the same basic
format as Volume 2.
MD0753 2-20
a. Begin with the Alphabetic Index. Locate the main term which will be in bold
type.
NOTE: Do not code directly from the Alphabetic Index.
b. Refer to the Tabular List to verify that the code number you have selected is
in accord with the procedure performed.
NOTE: There are many exclusion notes in the Tabular List. Read
and be guided by the exclusion terms and exclusion notes under the category and
subcategory.
c. Follow the instructions and any note to "code also." Use two or more codes to
completely code each component of a procedure.
NOTE: Remember the surgical approach and closure are part of the operation and do
not require codes in addition to the code for the operations, unless they are unusual or
required by the statement "code also."
d. Verify the code at the main 2-digit category for any added instructions.
Continue with Lesson Exercises
MD0753 2-21
EXERCISES, LESSON 2
REQUIREMENT. Complete the following exercises by marking the lettered response

that best answers the question, or by finishing the incomplete statement, or by writing
the answer in the space provided at the end of the question.
After you have completed the exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers with the solutions.
1. List the document that is used in classifying diseases and medical procedures:
___________________________________.
2. In coding diseases, the Alphabetical Index of the ICD-9-CM is used in

conjunction with:
___________________________________.
3. What is the first step in coding a diagnosis?
___________________________________.
4. What is the second step in coding a diagnosis?
___________________________________.
5. Which copies of the Inpatient Treatment Record Cover Sheet (ITRCS) are found
in the Inpatient Treatment Record (ITR)?
a. ______________________________.
b. ______________________________.
6. How are modifiers identified in the Alphabetical Index, Volume 2, of the

ICD-9-CM?
___________________________________.
MD0753 2-22
7. State two ways to locate a diagnosis in the Alphabetical Index, Volume 2 of the
ICD-9-CM, when that diagnosis begins with an eponym.
a. ______________________________.
b. ______________________________.
8. Which codes are used in the Alphabetical Index, Volume 2 to identify adverse
effects of drugs and chemicals that were properly administered?
___________________________________.
9. In the Tabular List of Volume 1 of ICD-9-CM, the first two digits of the number
indicate:
___________________________________.
10. What is the function of the third digit of a three-digit number in the tabular list of
volume 1 of ICD-9-CM?
___________________________________.
11. What is the Army's policy on the use of the fifth digit in making classifications with
the Tabular List of ICD-9-CM?
___________________________________.
12. What should you do when using Volume 1 to verify the code you have selected
for a disease or cause of injury diagnosis and a fourth digit is not provided by ICD-9-CM
or specified in the IPDS User's Manual?
___________________________________.
13. What type of codes are provided in Appendix A of the Triservice Disease and
Procedures Coding Guidelines?
__________________________________.
MD0753 2-23
For exercises 14 through 19, match each of the phrases, signs, symbols, and
abbrevations in the left-hand column with the description in the right-hand column that
best conveys its usage in the ICD-9-CM.
14. ___ Not Elsewhere Classified (NEC). a. Equivalent to

"unspecified" and
"unqualified."
15. ___ Not Otherwise Specified (NOS). b. Used to enclose

supplementary as part of
the physician’s
diagnosis/procedures
16. ___ Square Brackets [ ]. c. Added after terms

classified in unspecific
categories and to terms in
themselves ill-defined
17. ___ Parentheses ( ). d. Indicates an

incomplete term or
phrase which must have
a certain make it
assignable to a specific
category
18. ___ Braces {}. e. Used to connect a

series of words to a
common term.
19. ___ Colons : . f. Used to enclose

synonyms, alternate
wording, or explanatory
phrases
MD0753 2-24
Use Appendices B, C, and D, excerpts of the International Classification of
Diseases, 9 th Revision, Clinical Modification (ICD-9-CM), to code the
diagnoses and procedures in exercises 20 through 33.
NOTE: Remember that the Army does not use decimals when coding
diseases and procedures.
20. Swimmer's itch. _______________

21. Wax in the ear. _______________
22. Jaundice (yellow) fetus
due to infection _______________
23. Anorexia. _______________

24. Swelling of the tongue. _______________
25. Tooth reimplantation. _______________
26. Lack of physiological
development. _______________
27. Stripping varicose veins

in upper limb. _______________
28. Colostomy perineal loop. _______________

29. Refusion of spine. _______________
30. Primary malignant neoplasm, liver. _______________
31. Corneal transplant,
Keratoplasty with autograft,
penetrating (full-thickness). _______________
32. Laryngitis acute with

influenza. _______________
33. Goldthwaite operation,

ankle stabilization. _______________
Check Your Answers on Next Page
MD0753 2-25
1. The International Classification of Diseases, 9th Revision, Clinical Modification

(ICD-9-CM). (para 2-2a)
2. The Tabular Index of Volume 1, ICD-9-CM. (para 2-4a)
3. To locate the diagnoses in the Alphabetical Index, Volume 2, ICD-9-CM.

(para 2-13e)
4. To verify the diagnoses in the Tabular List, Volume 1, ICD-9-CM. (para 2-13e)
5. Handwritten physician's work copy and a typewritten copy. (para 2-13b)
6. By indentation under the main term. (para 2-14b)
7. a. Look under the name of the person for whom the disease or operation is
named.
b. Look under the main terms "Disease," "Syndrome," or "Tremor." (para 2-15b)
8. E-codes. (para 2-15g)
9. Important or summary groups. (para 2-16a)
10. Divides each group into categories representing specific disease entities or the
classification of the disease or condition. (para 2-16a)
11. The Army requires that 5th-digit classifications be used for more specificity.
(para 2-16c)
12. Disregard decimal points appearing in ICD-9-CM and add a fourth-digit of zero.
(para 2-17c)
13. DOD extender codes. (para 2-17f)
14. c (para 2-10a)
15. a (para 2-10b)
16. f (para 2-9b)
17. b (para 2-9a)
18. e (para 2-9d)
19. d (para 2-9c)
MD0753 2-26
APPENDICES
20. 1203 (C-7 and B-1)
21. 3804 (C-9 and B-3)
22. 7741 (C-2 and B-5)
23. 7830 (C-1 and B-6)
24. 7842 (C-7 and B-8)
25. 2350 (D-10 and D-2)
26. 7834 (C-3 and B-7)
27. 3853 (D-11 and D-3)
28. 4603 (D-7 and D-5)
29. 8108 (D-10 and D-6)
30. 1550 (C-5 and B-2)
31. 1163 (D-12 and D-1)
32. 4871 (C-4 and B-4)
33. 8111 (D-8 and D-6)
END OF LESSON 2
MD0753 2-27
LESSON ASSIGNMENT
LESSON 3 Inpatient Treatment Record Cover Sheet.
3-1. Identify the purpose of the Inpatient Treatment

Record Cover Sheet.
3-2. Identify the medical treatment facilities required

to use the Inpatient Treatment Record Cover Sheet.
3-3. Identify the procedures followed in distribution

of the Inpatient Treatment Record Cover Sheet.
3-4. Identify the person who is responsible for

completing different portions of the Inpatient
Treatment Record Cover Sheet.
3-5. Identify and define the information which is

extended on the Inpatient Treatment Record Cover
Sheet.
3-6. Given a blank Inpatient Treatment Record

Cover Sheet, accurately complete it using
information provided.

MD0753 3-1
LESSON 3
INPATIENT TREATMENT RECORD COVER SHEET
Section I. GENERAL
3-1. GENERAL
a. Purpose. AR 40-66, defines the purposes and use of DA Form 3647,

Inpatient Treatment Record Cover Sheet (ITRCS) as a medical and administrative
summary of each case. An Inpatient Treatment Record (ITR) consists of the ITRCS
and other forms prepared and used during a current, uninterrupted period of treatment
for a patient who is hospitalized. The ITRCS is an essential document for the Health
Record (HREC) and Outpatient Treatment Record (OTR). It also serves as a source
document for statistical information of major military and medical interest, and as a legal
document in third party liability cases.
b. Use of Inpatient Treatment Record Cover Sheet. All hospitals (fixed and
nonfixed) and convalescent centers are required to use the ITRCS. In overseas
commands, the ITRCS may also be used, at the discretion of the theater or command
surgeon, by clearing stations designated and staffed as nonfixed hospitals.
c. For Whom Prepared. The ITRCS is prepared for:
(1) All bed patients (military or civilian) admitted to a fixed or field hospital, or
convalescent center.
(2) Liveborn infants.
(3) Carded for Record Only (CRO) cases. CRO is a classification used for:
(a) Cases when the patient is dead on arrival at the medical treatment
facility (MTF).
(b) Disability separations/retirement (medical board) cases processed on

an outpatient basis.
(c) Selected medicolegal cases such as rape or assault. Such cases

require a record for the MTF.
d. Responsibilities.
(1) The MTF commander has the overall responsibility for the preparation,
safeguarding, and forwarding of inpatient records.
MD0753 3-2
(2) The health care provider is responsible for the day-to-day supervision
and maintenance of the inpatient record and for its completion, to include preparation of
the professional data on the ITRCS. The information provided on the ITRCS must be
adequate for medical, legal, and administrative purposes.
(3) The Chief, Patient Administration Division (PAD), is jointly responsible

with the health care provider for the preparation of the ITRCS and for other
administrative aspects of the ITRCS.
(a) The Medical Records Administration Branch acts for the Chief,
Patient Administration Division, in completing the administrative aspects of the ITRCS.
(b) While each medical treatment facility establishes the procedures for
processing the ITRCS, the Medical Records Administration Branch must ensure that the
ITRCS is accurate, coded, and complete and that the completed ITRCS is distributed in
accordance with AR 40-66 and AR 40-400 upon disposition of the patient.
3-2. DISTRIBUTION
a. Preparation. The ITRCS (DA Form 3647) is one of the forms initiated by
Admissions and Dispositions (AAD) at the time a patient is admitted to an MTF. It is
completed when the patient is transferred, is discharged, is returned to duty, dies, or is
a CRO case. The ITRCS comes in single or continuous form as a four-part carbon
pack. Usually, the last copy is used as a worksheet by the attending health care
provider. At the time of disposition, the information on the worksheet is transcribed onto
the remaining three forms.
b. Distribution of ITRCS. The ITRCS is distributed for completed or transferred

cases. The original and copies are distributed as follows:
(1) The original copy is placed in the ITR.
(2) The first carbon copy is placed in the patient's Health Record or
Outpatient Treatment Record, as appropriate.
(3) The second carbon copy is placed in the register number index, in
register number sequence.
(4) The third (or last) carbon copy (doctor's handwritten worksheet) is placed
after the original typewritten copy in the ITR.
NOTE: MEDDACs will maintain a register number index for 5 years. MEDCENs do
not need to maintain this index because the ITRs are maintained at the MEDCEN for 5
years. In facilities using the Composite Health Care System (CHCS) or Automated
Quality of Care Evaluation Support System (AQCESS), an automated version of DA
Form 3647 will be printed. The worksheet copy will not be provided.
MD0753 3-3
3-3. ABBREVIATIONS
a. Authorized Abbreviations. AR 40-66 and AR 310-50 contain abbreviations

authorized for Army-wide use.
b. Other Authorized Abbreviations. Certain other abbreviations are

authorized for use in preparing the ITRCS with the exception that all final diagnoses are
recorded in full without the use of either symbols or abbreviations. Abbreviations in
medical dictionaries as well as common abbreviations found in standard dictionaries are
acceptable. Additional abbreviations used on the ITRCS are shown in table 3-1.
Absent Sick Abs Sk

Accidentally Incurred AI
Against Medical Advice AMA
Armed Services Medical Regulating Office ASMRO
Army Community Hospital (e.g., Kirk ACH) ACH
Battle Casualty BC
Carded for Record Only CRO
Diagnosis Dg
Direct Dir
Disease Dis
Existed Prior to Service EPTS
Injury Inj
Medical Evaluation Board MEB
Medical Treatment Facility MTF
Multiple Mul
Newborn NB
Nonbattle Injury NBI
Permanent change of station PCS
Permanent Disability Retirement List PDRL
Physical Evaluation Board PEB
Previously Recorded PR
Seriously Ill SI
Subsisting Out Sub Out
Temporary Disability Retirement List TDRL
Transfer to Army MTF TAR
Transfer to Air Force MTF TAF
Transfer to Navy MTF TNF
Very Seriously Ill VSI
Table 3-1. Abbreviations used on the ITRCS
MD0753 3-4
Section II. COMPLETION OF THE INPATIENT TREATMENT RECORD COVER
SHEET
3-4. GENERAL
a. Format. The format is the same for two variations of the Inpatient Treatment
Record Cover Sheet (ITRCS).
(1) DA Form 3647 (original and three carbon set) used for typed entries of
patient data (see figure 3-1).
(2) DA Form 3647 (original and three carbon set) used for computer
generated, continuous form printing (see figure 3-2).
b. Initial Information. The source of data for Items 1 through 30, (except Items
25, 26, and 33) is DA Form 2985 (Admission and Coding Information). DA Form 2985
is a dual purpose form serving as a patient admission information document and coding
transcript. It is used in Army medical treatment facilities (MTFs) not having automated
admission and disposition/clinical records processing. The initial information is
obtained by the admissions clerk. Nonautomated hospitals should complete applicable
fields of DA Form 2985 in an original and two legible copies at the time of admission.
The information is transferred from DA Form 2985 by typing the items onto DA Form
3647 (see figure 3-3). The remainder of the information is obtained from the ITRCS
after the patient is dispositioned and the ITRCS is completed.
c. Attending Physician. The health care provider in charge of the case is

responsible for the diagnostic/operative information recorded in Item 34, this information
is verified by completion of the "Signature of Attending Medical Officer" block on the
ITRCS physician's worksheet.
d. Disposition Information. This information is completed by the Patient

Administration Division at the time of disposition of the patient. The ITRCS is completed
when the patient is discharged, returned to duty, transferred, dies, or is a CRO case.
This information is covered in detail in the next few paragraphs.
e. Recording of Dates. The dates are entered in sequence of day, month, and
year. Numerical symbols for months are not authorized.
f. CRO Cases. When preparing an ITRCS for CRO cases, Items 7, 14, 24, 27,
and 30 and name of admitting officer are not required.
g. Correction of ITRCSs. A corrected ITRCS must be completed and

forwarded as necessary to correct any item (except for MTF code and register number
which cannot be changed in the IPDS data base by the MTF). A corrected ITRCS must
include the register number, name of patient, FMP-SSN, date of disposition, and MTF
name as well as the information corrected. Both the erroneous entry and corrected
MD0753 3-5
entry must be shown using the "line out and underline" method. The ITRCS then must
be clearly marked as "corrected record" in the top margin and forwarded IAW
instructions in lesson 4.
3-5. COMPLETION OF THE ITRCS
a. Items 1 through 30. Nonautomated sites obtain this information from the
Admission and Coding Information Form (DA Form 2985) except for Items 25 and 26,
and transfer it to the ITRCS (see figure 3-3). The ITRCS is computer-generated by the
Automated Quality of Care Evaluation Support System (AQCESS) or the Composite
Health Care System (CHCS) in automated sites.
b. Item 25, Type Disposition.
(1) When a patient is transferred to another U.S. Armed Forces MTF, record
the name of the receiving MTF, e.g., TAR Brooke AMC. Continue in Item 31, if
necessary.
(2) When a military member is placed on change-of- status-out to PCS Home

to await the processing of a separation or retirement, the ITR will not be closed out until
the effective date of the separation/retirement from service. For these cases, indicate
the type and date of the action.
(3) Whenever a military member is retired or separated, cite the appropriate

Army regulation. For separations under AR 635-200, i ndicate the reason, e.g., failure to
meet medical procurement standards, expiration of term of service, etc. When a patient
is retired or separated for physical disability, state whether permanent or temporary, or
whether separation is with or without severance pay. When a patient is moved to a VA
hospital, so state.
(4) If a nonmilitary patient leaves the hospital against medical advice, record
as "left against medical advice (AMA)." If a military patient leaves the hospital against
medical advice, he would be considered absent without leave (AWOL).
(5) For a case terminating in death, enter "died" and indicate whether or not
an autopsy was performed, e.g., "Autopsy: Yes" or "Autopsy: No."
MD0753 3-6
Figure 3-1. DA Form 3647 (Inpatient Treatment Record Cover Sheet
for typed entries).
MD0753 3-7
Figure 3-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet
for computer generated entries).
MD0753 3-8
Figure 3-3. Relationship of DA Form 2985 and DA Form 3647.
MD0753 3-9
c. Item 31, Selected Administrative Data.
(1) Board proceedings. Enter the date and findings of Medical Evaluation
Board (MEB) and Physical Evaluation Board (PEB) proceedings. Include applicable
regulation (AR 635-40 or AR 635-200) and paragraph numbers directing
separation/retirement. In these cases, also enter the profile(s) necessitating medical
separation/retirement.
(2) For patients transferred. Enter the Armed Services Medical Regulating
Office (ASMRO) cite number, patient movement category, and in the case of urgent or
priority cases, the name of the accepting physician.
(3) Patient absence. Note if patient is on convalescent or ordinary leave,

pass, AWOL (10 days or less), TDY, subsisting out, PCS home, absent sick, or in
supplemental care or cooperative care status. Include the appropriate status, name,
and location of the facility, and the initial and final dates of treatment for absent sick,
cooperative care, or supplemental care. For example, "Supplemental Care to Medical
Center Hospital, San Antonio, TX, from 16 MAR 9X to 25 MA R 9X." An ITRCS
reflecting a figure in Items 35a through 35d, or 36a through 36d should have that figure
broken out in the "Selected Administrative Data" block (Item 31) of the ITRCS.
(a) Absent without leave (AWOL). A military patient leaving the MTF
without permission will be carried on the rolls as AWOL for 10 consecutive days only.
On the 11th day, the Inpatient Treatment Record will be closed out as an AWOL.
Should the patient return to the MTF prior to the expiration of 10 days, the date of return
will be noted. If the patient returns after 10 days and still requires medical care, the
patient will be admitted as a direct admission, assigned a new register number, and a
new Inpatient Treatment Record will be initiated.
(b) Period of TDY. Patients may, under specific circumstances, be

placed on TDY at another hospital or to appear before a Physical Evaluation Board
(PEB) or at a military installation. In such cases, an entry will be made of the fact and
inclusive dates of the TDY status, e.g., "TDY Ft Sam Houston for PEB appearance 6-11
Sep 9X."
(4) Very Seriously Ill (VSI) and Seriously Ill (SI) Patients. AR 40-2 defines
these categories of patients and prescribes the preparation of reports and notifications
related to them. Remarks will be entered reflecting a clear and chronological outline of
the patient's VSI and SI status, e.g., "SI 24 Jun 9X to 25 Jun 9X, removed from VSI/SI
Roster 26 Jun 9X or SI 24 Jun 9X and remains SI at time of transfer."
(5) Neonatal death. Enter the te rm "Neonatal Death" along with a statement
of the infant's age at death. State age in completed hours for death in the first 24 hours
of life, in completed days for deaths after the first day of life, e.g., "Neonatal death less
than one hour after delivery" or "Neonatal death, age 26 days."
MD0753 3-10
(6) Newborn to Pay Status . If the mother is discharged and the infant
remains, a change of status from newborn to pay status is required. Enter the date of
change of status.
d. Item 32, Units of Whole Blood/Component Transfused. Record the

number of units of whole blood or blood components transfused. (A unit is the basis of
issue of blood or blood component.) If no transfusion was given, leave this space blank.
e. Item 33, Cause of Injury.
(1) If the patient was treated for an injury (including any adverse reaction to
chemical or other external cause) or for any residual effects resulting from an injury not
previously recorded, state the circumstances under which the injury was incurred. When
recording an injury, specify the following:
(a) The external causative agent, including, in the case of acute

poisoning, the name of the poison.
(b) The circumstances under which the injury occurred, including the
activity in which the person was engaged at the time of injury, e.g., whether the person
was in action against the enemy, on work detail, marching or drilling, on an obstacle
course run, handling firearms on the range, cleaning a rifle, or participating in athletics.
For motor vehicle accidents, indicate the kind of vehicle(s) involved and the ownership
of the vehicle, e.g., military or other.
(c) Whether the injury was deliberately self-inflicted as an act of

misconduct (injury self-inflicted to avoid duties) or as an act of mental instability (a
suicide or attempted suicide), or was deliberately inflicted by another person, or
accidentally incurred.
(d) The place the injury occurred, e.g., location on post such as the
barracks, dining hall, motor pool; if off post, location and status such as home on leave,
in transit when absent without leave, etc.
(e) The date the injury occurred.
(f) Whether the military member was engaged in assigned duties and
the nature of the duties.
(2) An example of properly recorded cause of injury information is "Caused

by rifle bullet; accidentally incurred when patient's rifle discharged while he was cleaning
it in Barracks A, Fort Dix, NJ, 8 Jul 9X."
(3) Additional information is needed for battle casualties. This information

includes: whether the casualty was caused by enemy action, the kind of missile or
MD0753 3-11
agent causing the casualty, and the general geographic location of the patient at the
time of injury.
f. Item 34, Diagnoses/Operations and Special Procedures.
(1) Recording ICD-9-CM codes. ICD-9-CM coding principles are outlined in

lesson 2. An ICD-9-CM code should be recorded to the left of the diagnosis/operation
entry to which it pertains.
(2) Recording of diagnoses. Record all diagnoses that affect the current,
uninterrupted period of treatment. Record and code unusual manifestations, e.g.,
scarlet fever with acute nephritis. Do not record the admitting or provisional diagnosis.
Do not record diagnoses that relate to earlier admissions, or are status-post conditions,
or physical findings which have no bearing on this period of treatment.
(a) The principal diagnosis is the condition (diagnosis) established after

study to be responsible for the admission of the patient to the hospital. The attending
physician must confirm the principal diagnosis, and it must be substantiated by the
documentation in the medical record.
(b) The primary diagnosis is the condition (diagnosis) which is primarily

responsible for using the greatest amount of hospital resources (it may or may not be
the principal diagnosis).
(c) Comorbidity is a preexisting condition that will cause an increase in

length of stay in approximately 75 percent of cases, because of its presence with a
specific diagnosis.
(d) Complication is a condition arising during the hospital stay that

prolongs the length of stay.
(e) Diagnoses should be numbered consecutively as they are entered on

each Inpatient Treatment Record Cover Sheet. The principal diagnosis will always be
diagnosis number one. Indicate all conditions which are found to have been present
during this period of treatment, even though established after death. Use the notation
"Established Postmortem" as appropriate. List the specific drugs involved in an
overdose case.
(f) Cause of admission. The principal diagnosis, whether as a direct or

transfer admission, should be considered the cause of admission and so recorded. A
patient admitted in respiratory distress (later diagnosed as bronchopneumonia) who
also has hypertension would have bronchopneumonia recorded as the cause of
admission. In cases of several related conditions occurring simultaneously which
require the patient's admission, the condition first in the chain of etiology should be
designated as the cause of admission. For unrelated but simultaneously occurring
conditions requiring admission, the most serious condition will be recorded as the cause
of admission. In instances where two or more diagnoses could be selected due to the
MD0753 3-12
complexity of the case, the selection will be a matter of judgment. The cause of
admission diagnosis should be the first diagnosis entry on the Inpatient Treatment
Record Cover Sheet and coded in Field 38 of the Admission and Coding Form.
(3) Recording of operations and special procedures. Date and record all
operations and procedures performed during the current hospitalization, including those
performed prior to transfer into your MTF. Record the principal procedure first,
regardless of the date it was performed. Record only "exchange" and "intrauterine"
transfusions in Item 34.
(4) Residual disability. Leave this field blank.
(5) Special information on death. For cases terminating in death, all

conditions found to have been present during the period of treatment, even though
established after death, must be recorded with the notation "Established postmortem,"
when appropriate. In cases of suicide, homicide, or death by legal execution,
information characterizing the death will be included in addition to the required
diagnostic data.
(6) Deliveries. The mother's record should include the following:
(a) Presentation of each fetus with indication of live birth or stillbirth

except in case of a delivery by cesarean section. Terminology for recording
presentation of fetus can be found in The Standard Nomenclature of Diseases and
Operations .
(b) Previous Cesarean section, if any.
(c) Duration of pregnancy in weeks.
(d) The cause of fetal death and birth weight in the case of a stillbirth.
(7) Liveborn infants - additional information. A separate Inpatient Treatment

Record is required for each infant born in the reporting MTF. Record the following on
the ITRCS:
(a) Whether the infant is a single birth or one of multiple births. If the
latter, indicate also whether all mates were liveborn or if one or more were stillborn.
(b) Gestational age and birth weight. Record birth weight in grams.
(8) Drug overdoses. The Inpatient Treatment Record Cover Sheet on

overdose cases must include all sufficient information to apply the coding principles
outlined in Appendix A. (See principle IV Adverse Effects of Drug and E Codes.)
MD0753 3-13
g. Item 35, Total Days This Facility. This facility refers to the reporting facility
(MTF), the MTF where the Inpatient Treatment Record Cover Sheet is being completed.
(1) Item 35a, Absent Sick Days.
(a) If the patient has absent sick days, record this information in Item 31.
Absent sick days are the days an Army service member is an inpatient in a nonmilitary
MTF.
(b) If no absent sick days are recorded in Item 31, leave Item 35a blank.
(2) Item 35b, Other Days .
(a) Enter the number of days subsisting out in Item 35b.
(b) Enter the number of days AWOL (10 days or less) in Item 35b.
(c) Enter any other days not recorded in Items 35a, c, d, or e.
(3) Item 35c, Convalescent Leave/Cooperative Care Days .
(a) Enter convalescent leave/cooperative care days in 35c.
(b) If there are no convalescent leave/cooperative care days, leave

blank.
(4) Item 35d, Supplemental Care Days .
(a) Enter supplemental care days in 35d.
(b) If there are no supplemental care days to report, leave blank.
(5) Item 35e, Bed Days.
(a) Enter in 35e only those days in which a patient occupies a bed or
bassinet.
(b) Days recorded in 35a, b, c, or d are not bed days.
(6) Item 35f, Total Sick Days.
(a) Enter the total of 35a, b, c, d, and e.
(b) Count the day of admission but do not count the day of disposition in
computing the total sick days. To double check the total number of days, subtract the
day of admission from the day of disposition.
MD0753 3-14
(c) Carded for Record Only (CRO). Enter "0" in Item 35f only; Items
35a, b, c, d, and e should not have entries.
h. Item 36, Total Days All Facilities. Used for transfer admissions only. The
sources of data for this item is admission and disposition and the patient's ITR.
(1) An ITRCS should be prepared each time a patient is transferred from one
MTF to another. Item 36 is the summation of all transfer ITRCS.
(2) For direct admissions, leave Item 36 blank.
(3) For total days, include the following and compute using the date of initial
admission and date of disposition.
(a) Item 36a = the total absent sick days.
(b) Item 36b = the total other days.
(c) Item 36c = the total convalescent leave/cooperative care days.
(d) Item 36d = the total supplemental care days.
(e) Item 36e = the total bed days.
(f) Item 36f = the total sick days (the summation of Items 36a, b, c, d,
and e. This information should be taken from the date of initial admission recorded in
Item 30 and from Item 31 of all ITRCSs received from other facilities.
i. Automated MTFs. The completion of Items 35 and 36 are system-generated

by AQCESS/CHCS.
j. Signature of Attending Medical Officer. Typed signature blocks are

required for the attending physician, dentist, podiatrist, midwife, and other authorized
health care provider when in charge of a case. ITRCSs for CRO-DOA cases (when
death is pronounced by other than military MTF) and for cases where the entire bed
occupancy was in absent sick status require only the signature of the patient
administrator or medical records officer.
k. Signature of Medical Records Officer or Patient Administrator. Ensure

that the signature of the patient administrator or medical records administrator is
annotated. The medical records administrator or the patient administrator will sign each
completed ITRCS, thereby certifying to an accurate transcription of the worksheet
signed by the provider. Signature stamps are permitted for use by the medical records
administrator or the patient administrator.
MD0753 3-15
3-6. DOCUMENT FLOW OF INPATIENT TREATMENT RECORD COVER SHEET
a. Initial Preparation. The ITRCS must be initiated in the Admission and

Disposition Office (AAD) when a patient is admitted, and Items 1 through 30 (except for
Items 25 and 26) are completed. Nonautomated sites will use DA Form 2985
(Admission and Coding Information) as a source document. At automated sites, the
ITRCS is computer-generated by the Automated Quality of Care Evaluation Support
System (AQCESS) or the Composite Health Care System (CHCS).
b. Initial Flow. Local procedures prescribe the flow of the ITRCS. In some
Army hospitals, the AAD sends the original and three copies of the ITRCS, along with
the Inpatient Treatment Record jacket and the Admission and Coding Form to the
inpatient record area for filing in a suspense file pending disposition of the patient. In
other hospitals, AAD maintains the suspense file on ITRCS and related forms until
disposition of the patient. Still other hospitals send the ITRCS to the ward for filing until
disposition of the patient. The worksheet copy (third copy) is always sent to the ward
for use by the health care provider and filed in the patient's chart.
c. Disposition Flow. When the patient is dispositioned, the worksheet copy of

the ITRCS is completed and signed by the health care provider. This worksheet and
other documents in the patient's chart are used to complete the other three copies of the
ITRCS. The personnel in the Medical Records Administration Branch are responsible
for reviewing the ITRCS for completeness and accuracy. The DA
Form 2985 (Admission and Coding Information) is completed from the ITRCS. The
copies of the completed ITRCS are then distributed in accordance with AR 40-66 and
AR 40-400.
MD0753 3-16
EXERCISES, LESSON 3
INSTRUCTIONS. Complete the following exercises by marking the lettered response

that best matches the exercise, or by finishing the incomplete statement, or by writing
the answer in the space provided at the end of the question.
After you have completed the exercises, turn to "Solutions to Exercises" at the end of
the lesson and check your answers with the solutions.
1. What information is required in Item 33 of the Inpatient Treatment Record Cover

Sheet when a patient is treated for an injury?
________________________________________________________________
________________________________________________________________
________________________________________________________________
2. An ITRCS is prepared as an original and three copies. What is the final distribution
of the ITRCS?
a. ______________________________.
b. ______________________________.
c. ______________________________.
d. ______________________________.
3. When a patient has more than one operation and/or procedure, what sequence is
used to record these multiple operations and/or procedures?
________________________________________________________________
4. What is the purpose of the Inpatient Treatment Record Cover Sheet?
________________________________________________________________
________________________________________________________________
________________________________________________________________
MD0753 3-17
5. Administrative information on convalescent leave is recorded in Item______ of the
ITRCS. Then, at the time of disposition, the information on convalescent leave is used
in completing Item ______.
6. How does the health care provider in charge of a case verify the
diagnostic/operative information recorded in Item 34 of the Inpatient Treatment Record
Cover Sheet?
________________________________________________________________
7. On the Inpatient Treatment Record Cover Sheet, Item 36, Total Days All Facilities,
is used for direct admissions only.
a. True.
b. False.
8. Total bed days and total sick days are always equal.
a. True.
b. False.
9. Which Army regulation establishes the purpose and use of the Inpatient Treatment
Record Cover Sheet?
________________________________________________________________
10. Who is responsible for preparation of the ITRCS and other administrative aspects
of the ITRCS?
________________________________________________________________
11. The format is the same for the two variations of the Inpatient Treatment Record
Cover Sheet (ITRCS). What is the form number and two variations?
a. ______________________________.
b. ______________________________.
MD0753 3-18
12. Which medical treatment facilities are required to use the Inpatient Treatment
Record Cover Sheet?
________________________________________________________________
13. Which copy of the Inpatient Treatment Record Cover Sheet is usually used and
distributed as the worksheet?
________________________________________________________________
14. Nonautomated sites obtain data for items 1 through 30 (except Items 25 and 26) of
the Inpatient Treatment Record Cover Sheet from what source?
________________________________________________________________
15. Name the three categories of patients for whom the Inpatient Treatment Record
Cover Sheet is prepared.
a. ______________________________.
b. ______________________________.
c. ______________________________.
16. Define the following abbreviations.
a. PR: ___________________________.
b. NB: ___________________________.
c. ACH: __________________________.
d. Abs Sk: ________________________.
e. MEB: __________________________.
f. SI: ____________________________.
g. AMA: _____________________________.
h. TDRL: ____________________________.
MD0753 3-19
Exercises 17 through 20 provide data about individual patients. For each patient,
complete items 25, 26, and 31 through 36 (if applicable) on the ITRCS provided on the
following pages. Use the codes listed below for the appropriate condition of each
patient.
• 4809 Viral Brochopneumonia

• 49390 Asthma
• Congestive Heart Failure
• Ulcer of Duodenum with Hemorrhage
• Chrondromalacia of patella
17. RAMEY, WILLIAM P. The patient was dead on arrival in the emergency room.
The diagnosis CONGESTIVE HEART FAILURE (established postmortem) was
determined by autopsy.
18. TINDALL, HOWARD W. On 8 Dec 9X, the patient was a transfer to the United
States Army Hospital (USAH) at Fort Splendid. He had been placed on the VSI list on
27 Nov 9X, was upgraded to SI on 29 Nov 9X, and remained SI at the time of transfer.
His diagnoses were (1) ULCER OF DUODENUM WITH HEMORRHAGE and
(2) ACUTE NORMOCYTIC ANEMIA DUE TO BLOOD LOSS. The patient received two
units of blood, and was returned to duty, 15 Dec 9X.
19. BIRCHETT, JOANN M. The patient was returned to duty 10 Dec 9X. During her
hospitalization, she was treated for (1) VIRAL BRONCHOPNEUMONIA and (2)
CHRONIC ASTHMA. The second diagnosis was previously recorded (PR: FAMC,
Denver, CO, 15 Apr 8X).
20. KRAFT, CHRISTOPHER M. On 19 Nov 9X, the patient was a transfer to USAH,
Fort Splendid. His diagnosis was CHONDROMALACIA OF (right) PATELLA. This
condition existed prior to service (EPTS) and was previously recorded (PR: WRAMC,
Washington, DC, 26 Sep 8X). On 20 Nov 9X, he was taken to surgery for a partial
patellectomy. On 26 Nov 9X, a medical evaluation board (MEB) recommended referral
to a physical evaluation board (PEB). On 30 Nov 9X, the PEB recommended TDRL.
The patient was on convalescent leave 5 Dec 9X to 30 Dec 9X (25 days). On 31 Dec
9X, the patient was placed on TDRL (under provisions of AR 635-40).
Check Your Answers
MD0753 3-20
Figure 3-4. DA Form 3647 for Exercise 17.
MD0753 3-21
MD0753 3-22
MD0753 3-23
MD0753 3-24
1. Circumstances; causative agent; whether injury was deliberately self-inflicted or

inflicted by another person; place and date injury occurred, whether injury occurred
during duty/nonduty; and nature of duty. (para 3-5e(1)(a) -- (f))
2. a. Original to: Inpatient Treatment Record.

b. Copy 1 to: Health Record/Outpatient Treatment Record.
c. Copy 2 to: Register Number Index.
d. Copy 3 (Worksheet Copy) placed after the original in the Inpatient
Treatment Record. (para 3-2b(1) -- (5))
3. Principal procedure first, regardless of date, then in chronological sequence

(para 3-5f(3))
4. To serve as a medical and administrative summary of each case; an essential

document for Health Record/Outpatient Treatment Record; a source document for
medical statistical information, and a legal document for third party liability cases.
(para 3-1a)
5. 31; 35c. (para 3-5c(3) and para 3-5g(3))
6. Signature in appropriate block on ITRCS physician's worksheet copy. (para 3-4c)
7. b (para 3-5h)
8. b (para 3-5g(5)(b))
9. AR 40-66. (para 3-1a)
10. Chief, Patient Administration Division and the health care provider. (para 3-1d)
11. a. DA Form 3647 for typed entries.

b. DA Form 3647 for computer-generated continuous form printing.
(para 3-4a(1), (2))
12. All hospitals and convalescent centers. (para 3-1b)
13. The third (or last) copy. (para 3-2b(4))
14. Admission and Coding Information (DA Form 2985). (para 3-5a)
15. a. All admissions as bed patients.

b. Liveborn infants.
c. Carded for Record Only (CROs) cases. (para 3-1c(1) -- (3))
MD0753 3-25
16. a. Previously recorded.
b. Newborn.
c. Army community hospital.
d. Absent sick.
e. Medical evaluation board.
f. Seriously ill.
g. Against medical advice.
h. Temporary disability retirement list. (para 3-3b)
See next four pages for solutions for Exercises 17 through 20.
END OF LESSON 3
MD0753 3-26
Figure 3-8. DA Form 3647, Solution for Exercise 17.
MD0753 3-27
MD0753 3-28
MD0753 3-29
MD0753 3-30
LESSON ASSIGNMENT
LESSON 4 Individual Patient Data System.
4-1. Identify the purposes of the Individual Patient

Data System.
4-2. Given a completed Inpatient Treatment Record

Cover Sheet, extract data for coding DA Form 2985
(Admission and Coding Information).
4-3. Define terms related to the Individual Patient

Data System.
4-4. Identify forms used in the Individual Patient

Data System.
4-5. List the transmittal procedures used in the

Individual Patient Data System.
4-6. Identify data reduction procedures as it relates

to the Individual Patient Data System.
4-7. Identify procedures to code DA Form 2985

(Admission and Coding Information) from DA Form
1380 (U.S. Field Medical Card).

MD0753 4-1
LESSON 4
INDIVIDUAL PATIENT DATA SYSTEM
Section I. GENERAL
4-1. PURPOSE OF THE INDIVIDUAL PATIENT DATA SYSTEM
a. The Individual Patient Data System (IPDS) is a computer-oriented collection

of demographic and medical data on inpatients treated by the Army Medical Department
(AMEDD). Also included are other cases of sufficient interest that require reporting as
carded for record only (CRO) and data on active duty Army personnel treated in an
absent sick status in nonmilitary medical treatment facilities (MTFs). Authority and
responsibility to operate the IPDS are prescribed in AR 40-400.
b. The IPDS provides the following:
(1) Data for planning, managing, and evaluating the AMEDD medical care
system at Headquarters, Department of the Army (HQDA), major Army command
(MACOM) headquarters, and individual MTF levels.
(2) Data for medical and epidemiological research.
(3) Rapid data retrieval in response to inquiries from HQDA, Medical

Command (HSC), Office of The Surgeon General (OTSG), other DA components,
Department of Defense (DOD), Congress, Federal agencies, and other authorized
organizations and individuals.
(4) Management reports and retrieval of special data for the hospital
commander and his staff.
4-2. IPDS HANDBOOK
Information in this lesson is taken from the Individual Patient Data System (IPDS)
User's Manual published by the Patient Administration Systems and Biostatistics
Activity, U.S. Army Medical Department Center and School, Fort Sam Houston, Texas.
The IPDS User's Manual contains detailed procedures and instructions for processing
medical information extracted from inpatient treatment records into a prescribed format
for the IPDS. It also provides a description of output reports produced by the IPDS.
4-3. EXPLANATION OF TERMS
There are terms associated with the Admissions and Dispositions (AAD) forms
that will be used throughout this lesson. It will be to your advantage to become familiar
with the following terms:
MD0753 4-2
a. Code. Numeric or alphabetic characters that are assigned to specific
information in the prescribed IPDS format.
EXAMPLE: Data
Codes Explanation
AB Cardiology Clinic
A10 Active duty Army
b. Field. An area assigned to a particular category of information. Each field is

assigned a sequential category number. Within the field are one or more separately
numbered spaces referred to as columns.
EXAMPLE: 1. REPORTING MTF is the field.
1. REPORTING MTF
1 2 3 4 5 6
c. Column. Each of the small blocks within a field is a column.
EXAMPLE: Blocks 1-6 are columns.
1 2 3 4 5 6
d. Item. Refers to an entry on DA Form 3647 (Inpatient Treatment Record

Cover Sheet).
EXAMPLE: Item 1 on the cover sheet is the register number.
1. REGISTER NUMBER
MD0753 4-3
NOTE: Fields, columns, and items corresponding with these examples are found on
DA Form 2985 (Admission and Coding Information) which initiates the documenting of
medical information (see figure 4-1) and DA Form 3647 (see figure 4-2).
4-4. SOURCES OF DATA
a. DA Form 2985 (Admission and Coding Information) (see figure 4-1) is a dual
purpose form used as a patient admission information document and coding transcript
in Army MTFs not having automated admission and disposition/clinical records
processing. Fields on the DA Form 2985 have been arranged so that most of the
demographic and administrative data are on page 1 of the three-page form. This allows
page 1 of the form to be completed in its entirety once disposition of the patient is made.
Information on page one of the form is used to generate management reports.
NOTE: DA Form 2985 is known as the A&C Form.
b. The A&C Form is also designed so that most of the information needed to
complete page 1 is derived from the patient interview at the time of admission. The
remaining information must be obtained from the Inpatient Treatment Record Cover
Sheet (ITRCS) (see figure 4-2) after the patient has been dispositioned.
4-5. PROCEDURES
a. Nonautomated hospitals should complete applicable fields of the A&C Form in

an original and two legible copies at the time of admission.
b. Codes must be written legibly to avoid errors in data reduction. Alphabetical

characters must be printed as capital block letters; these codes do not contain lower
case letters. Zero must always be written Ø. The alphabetical characters "O," "S," "U,"
and "Z," must always be written as "O," "S," "U," and "Z."
c. Maintain the original and legible copies of the A&C Form in a suspense file
while the patient remains in an inpatient status.
d. At the time of disposition, remove the original and legible copies of the
A&C Form from the suspense file and complete the applicable fields on Page 1 of the
form.
e. Forward the A&C Form to the Medical Records Administration Branch for
filing in the patient's terminal digit file folder to await completion of the Inpatient
Treatment Record (ITR).
f. Upon completion of the ITR, remove the A&C Forms from the patient's
terminal digit file folder and complete pages 2 and 3 of the form.
g. File the original A&C Form (DA Form 2985) in the patient's ITR.
MD0753 4-4
Figure 4-1. DA Form 2985 (Admission and Coding Information) (continued).
MD0753 4-5
Figure 4-1. DA Form 2985 (Admission and Coding Information) (continued).
MD0753 4-6
Figure 4-1. DA Form 2985 (Admission and Coding Information) (concluded).
MD0753 4-7
Figure 4-2. DA Form 3647 (Inpatient Treatment Record Cover Sheet).
MD0753 4-8
h. Forward one legible copy of the A&C Form and the Inpatient Treatment
Record Cover Sheet (DA Form 3647) (ITRCS) to The U.S. Army Medical Department
Center and School, Patient Administration Systems and Biostatistics Activity (PASBA)
for input into the IPDS data base only if your facility is a non-fixed MTF.
i. Maintain one legible copy locally in a register number file with a copy of the
related (ITRCS) for future reference.
Section II. CODING OF DA FORM 2985
4-6. GENERAL
a. This section of the lesson will explain how patient information, (administrative
and medical) is coded on the A&C Form (DA Form 2985) for entry into the Individual
Patient Data System (IPDS) database. The instructions have been taken from the IPDS
User's Manual.
b. Instructions related to information obtained during the admission interview are

covered in Subcourse MD0752 (lesson 1, Admission and Disposition).
c. Information and examples in the following paragraphs have been taken from
figures 4-1 and 4-2 for the purpose of leading you through the coding of each field or
space on the DA Form 2985.
4-7. REPORTING MEDICAL TREATMENT FACILITY (MTF) (FIELD 1, COLUMNS 1

THROUGH 5)
a. Source of data : Table of MTF codes (see table 4-1).
b. An "A" for Army is printed in the first position (column 1) of the A&C Form.
Find the code for your MTF in table 4-1 and enter it the next four columns (2-5) of field
1, Reporting MTF as shown below:
EXAMPLE:
1. REPORTING MTF
1 2 3 4 5 6
A 1 4 1 1
c. Code 1411 is used for Darnell ACH, Fort Hood, TX.
MD0753 4-9
0101 Tripler AMC, Oahu, HI 1111 Patterson ACH, Fort Monmouth, NJ
0111 Bassett ACH, Fort Wainright, AK 1121 Keller ACH, West Point, NY
0121 Gorgas ACH, Ancon, Panama 1131 Hawley ACH, Fort Harrison, IN
0211 USACH,SHAPE, Belgium 1201 Fitzsimons AMC, Denver, CO
0311 USACH, Berlin, Germany 1211 Evans ACH, Fort Carson, CO
0321 USACH, Bremerhaven, Germany 1221 Munson ACH, Fort Leavenworth, KS
0331 Frankfurt ARMC, Germany 1231 General Leonard Wood ACH,
0341 USACH, Heidelberg, Germany Fort Leonard Wood, MO
0351 Landstuhl ARMC, Germany 1241 Irwin ACH, Fort Riley, KS
0361 USACH, Nuernberg, Germany 1251 USAHC, Fort Sheridan, IL
0371 USACH, Bad Cannstatt, Germany 1301 Eisenhower AMC, Fort Gordon, GA
0381 USACH, Wuerzburg, Germany 1311 Martin ACH, Fort Benning, GA
0391 USACH, Augsburg, Germany 1321 Blanchfield ACH, Fort Campbell, KY
0421 USACH, Vicenza, Italy 1331 Moncrief ACH, Fort Jackson, SC
0611 121stst Evac Hosp, Seoul, Korea 1341 Noble ACH, Fort McClellan, AL
0711 USAMEDDAC, Camp Zama, 1351 Fox ACH, Redston Arsenal, AL
Japan (AHC) 1361 Lyster ACH, Fort Rucker, AL
1001 Walter Reed AMC, Washington, DC 1371 Winn ACH, Fort Stewart, GA
1011 USAMEDDAC (Wilcox AHC) 1401 Brooke AMC, Fort Sam Houston, TX
Fort Drum, NY 1411 Darnell ACH, Fort Hood, TX
1021 DeWitt ACH, Fort Belvoir, VA 1421 Bayne-Jones ACH, Fort Polk, LA
1031 Womack ACH, Fort Bragg, NC 1431 Reynolds ACH, Fort Sill, OK
1041 Cutler ACH, Fort Belvior, MA 1501 William Beaumont AMC, Fort Bliss, TX
1051 Walson ACH, Fort Dix, NJ 1511 Bliss ACH, Fort Huachuca, AZ
1061 McDonald ACH, Fort Eustis, VA 1601 Letterman AMC, San Francisco, CA
1071 Ireland ACH, Fort Knox, KY 1611 Silas B. Hays ACH, Fort Ord, CA
1081 Kenner ACH, Fort lee, VA 1631 Weed ACH, Fort Irwin, CA
1091 Kimbrough ACH, Fort Meade, Md 1701 Madigan AMC, Fort Lewis, WA
Table 4-1. Medical treatment facility (MTF) codes.
NOTE: The field in the above example, and the fields in other examples to follow in this
explanation, are enlarged fields of DA Form 2985. These and other codes will be used
for fictitious facilities, administrative and medical conditions, patients, and personnel for
instructional purposes only. Some information on DA Form 2985 will not require coding,
but must be verified as correct by comparison with the Inpatient Treatment Record
Cover Sheet (ITRCS).
d. The MTF codes listed above as well as Table of Organization and Equipment
(TOE) Hospital codes are listed in the Individual Patient Data System (IPDS) User's
Manual. Any codes not listed in that document will be assigned by PASBA. Point of
contact is Chief, Medical Summary Branch, Biostatistics Division, DSN 471-5579.
MD0753 4-10
4-8. MTF LOCATION (FIELD 2, COLUMNS 7 THROUGH 8)
a. Source of data. Table of MTF state location codes (see table 4-2).
| Alabama Ø1 Montana 3Ø
| Alaska Ø2 Nebraska 31
| Arizona Ø4 Nevada 32
| Arkansas Ø5 New Hampshire 33
| California Ø6 New Jersey 34
| Colorado Ø8 New Mexico 35
| Connecticut Ø9 New York 36
| Delaware 1Ø North Carolina 37
| District of Columbia 11 North Dakota 38
| Florida 12 Ohio 39
I Georgia 13 Oklahoma 4Ø
| Hawaii 15 Oregon 41
I Idaho 16 Pennsylvania 42
| Illinois 17 Rhode 44
| Indiana 18 South Carolina 45
| Iowa 19 South Dakota 46
| Kansas 2Ø Tennessee 47
| Kentucky 21 Texas 48
| Louisiana 22 Utah 49
| Maine 23 Vermont 5Ø
| Maryland 24 Virginia 51
| Massachusetts 25 Washington 53
| Michigan 26 West Virginia 54
| Minnesota 27 Wisconsin 55
| Mississippi 28 Wyoming 56
| Missouri 29
Table 4-2. State location codes.
b. Enter your MTF's state location code from table 4-2. State location codes, as well as
overseas country location codes are listed in the Individual Patient Data System (IPDS)
User's Manual. For TOE units, this is the deployment site, not the garrison location.
EXAMPLE:
2. MTF LOCATION
7 8 (State or
Country Code)
4 8
MD0753 4-11
4-9. REGISTER NUMBER (FIELD 3, COLUMNS 9 THROUGH 15)
a. Source of data. Assigned by AAD office at nonautomated sites. Assigned by

the Automated Quality of Care Evaluation Support System (AQCESS)/Composite
Health Care System (CHCS) at automated sites. (Item 1, ITRCS).
b. The register number should contain seven numbers. If not, zero fill to the left.
EXAMPLE:
3. REGISTER NUMBER
9 10 11 12 13 14 15
Ø 1 7 6 5 5 Ø
4-10. NAME
a. Source of data. Admission interview or the identification (ID) card.

(Item 2, ITRCS).
b. Enter the patient's name (last, first, middle initial). Include all initials for North
Atlantic Treaty Organization (NATO) patients. Enter the maiden name for maternity
patients.
EXAMPLE:
NAME (Last, First, Middle Initial)
DALLAS, KENNETH N.
MD0753 4-12
4-11. PAY GRADE (FIELD 4, COLUMNS 16 THROUGH 17)
a. Source of data. Admission interview or the ID card. (Item 3, ITRCS).
b. Enter the patient's pay grade as of the day of admission to your MTF. Use
table 4-3 for military members of all components, including foreign military members
and retirees of U.S. uniformed services. For nonmilitary patients, leave this field blank.
EXAMPLE:
4. PAY GRADE
16 17 PVT
E 1
ARMY NAVY/ MARINES COAST GUARD AIR FORCE DATA
CODES
GENERAL OF THE ARMY GENERAL OF THE FLEET ADMIRAL GENERAL OF 11
(GA) MARINES (GA) (FADM) THE AIR FORCE
Gen AF)
GENERAL (GEN) GENERAL MARINES ADMIRAL (ADM) GENERAL (GEN) 10
(GEN)
LIEUTENANT LIEUTENANT VICE ADMIRAL (VADM) LIEUTENANT 09
GENERAL (LTG) GENERAL (LTG) GENERAL (LTG)
AJOR GENERAL MAJOR GENERAL REAR ADMIRAL MAJOR ENERAL 08

(MG) (Maj Gen) (RADM) (MG)
BRIGADIER BRIGADIER COMMODORE BRIGADIER 07

GENERAL (BG) GENERAL (BG) (COMO) GENERAL (BG)
COLONEL (COL) COLONEL (Col) CAPTAIN (CAPT) COLONEL (COL) 06
LIEUTENANT COLONEL LIEUTENANT COMMANDER (CDR) LIEUTENANT O5

(LTC) COLONEL (Lt Col) COLONEL (LTC)
MAJOR (MAJ) MAJOR (Maj) LIEUTENANT MAJOR (MAJ) O4

COMMANDER (LCDR)
CAPTAIN (CPT) CAPTAIN (Capt) LIEUTENANT (LT) CAPTAIN (CPT) O3
FIRST LIEUTENANT FIRST LIEUTENANT LIEUTENANT FIRST O2

(1LT) (1st Lt) JUNIOR GRADE LIEUTENANT
(LTJG) (1st Lt)
Table 4-3. Grade codes (continued).
MD0753 4-13
ARMY NAVY/ COAST GUARD AIR FORCE DATA
MARINES CODES
SECOND SECOND ENSIGN (ENS) SECONDLIEUTENAN O1
LIEUTENANT (2LT) LIEUTENANT (2LT) T (2LT)
CHIEF WARRANT CHIEF WARRANT CHIEF WARRANT CHIEF WARRANT W4

OFFICER (CWO4) OFFICER (CWO4) OFFICER (WO4) OFFICER (CWO4)


WARRANT OFFICER WARRANT OFFICER WARRANT OFFICER WARRANT OFFICER W1

(WO1) (WO1) (WO1) (WO1)
SERGEANT MAJOR OF SERGEANT MAJOR MASTER CHIEF CHIEF MASTER E9

THE ARMY OF THE MARINE PETTY OFFICER OF THE AIR FORCE
(SMA) CORPS (Sgt Maj) THE NAVY (CMSgtAF)
(MCPON)
COMMAND SERGEANT MAJOR MASTER CHIEF CHIEF MASTER E9
SERGEANT MAJOR (Sgt Maj) PETTY OFFICER SERGEANT
(CMS) (MCPO) (CMSgt)
STAFF SERGEANT MASTER GUNNERY ____ ____ E9
MAJOR (SSM) SERGEANT
(MGy Sgt)
FIRST SERGEANT FIRST SERGEANT SENIOR CHIEF PETTY SENIOR MASTER E8
(1SG) (1st Sgt) OFFICER SERGEANT
(SCPO) (SMSgt)
MASTER SERGEANT MASTER SERGEANT ____ ____ E8
(MSG) (MSgt)
PLATOON GUNNERY ERGEANT CHIEF PETTY MASTER E7

SERGEANT (PSG) (Gy Sgt) OFFICER SERGEANT
Or SERGEANT (CPO) (MSgt)
FIRST CLASS (SFC)
STAFF SERGEANT STAFF SERGEANT PETTY OFFICER TECHNICAL E6

(SSG) (SSgt) FIRST CLASS SERGEANT
(PO1) (TSgt)
SERGEANT SERGEANT PETTY OFFICER STAFF SERGEANT E5
(SGT) (Sgt) (PO2) (SSgt)
CORPORAL (CPL) CORPORAL (Cpl) PETTY OFFICER SERGEANT (Sgt) E4

THIRD CLASS
(PO3)
SPECIALIST (SPC) ____ ____ ____ E4
Table 4-3. Grade codes (continued).
MD0753 4-14
ARMY NAVY/ COAST GUARD AIR FORCE DATA
MARINES CODES
PRIVATE FIRST LANCE CORPORAL SEAMAN SENIOR AIRMAN E3

CLASS (PFC) (LCpl) (Seaman) (SrA)
PRIVATE (PV2) PRIVATE FIRST SEAMAN AIRMAN FIRST E2

CLASS (PFC) APPRENTICE (SA) (A1C)
PRIVATE (PVT) PRIVATE (PVT) SEAMAN RECRUIT AIRMAN BASIC E1

(SR) (Amn)
CADET (Includes cadets of the uniformed services academies and ROTC cadets) CD
UNKNOWN (Not to be used for U.S. Army active duty personnel,

Army Reserve/National Guard, USMA cadets) ZZ
Table 4-3. Grade codes (concluded).
4-12. SEX (FIELD 5, COLUMN 18)
a. Source of data. Admission interview or ID card. (Item 4, ITRCS).
b. The MTF must make a choice in uncertain cases as in extreme deterioration

of remains in which a pathologist cannot make a determination.
c. Select sex code from table 4-4.
EXAMPLE:
5. SEX
18
DATA CODE
Male M
Female F
Table 4-4. Sex codes.
MD0753 4-15
4-13. DATE OF BIRTH (FIELD 6, COLUMNS 19 THROUGH 26)
a. Source of data. Admission interview or ID card.
b. Enter in succession, four digits for year of birth; two digits for birth month
(Ø-12); and two digits for day of birth (Ø1-31).
EXAMPLE:
6. DATE OF BIRTH (YYYYMMDD)

19 20 21 22 23 24 25 26
1 9 7 X Ø 4 1 3
4-14. AGE AT ADMISSION (FIELD 7, COLUMNS 27 THROUGH 29)
a. Source of data. Admission interview. For live births at your MTF and
transferred live births less than 24 hours old, enter ØØD. This is calculated by
AQCESS/CHCS from field 6, Date of Birth, and field 26, Date of This Admission.
(Item 5, ITRCS).
b. Enter the patient's age in completed days, months, or years at the time of this
admission to your MTF. For an infant delivered in a military MTF, enter data code ØØD
from table 4-5 and NB. For an infant born outside your facility (e.g., enroute to the
MTF), enter ØØD. For other infants under 1 month old, enter the age in days (e.g.,
18D). For a child 1 month but less than 12 months old, enter the age in completed
months (e.g., Ø2M). If a patient is 1 year or older, enter the age in completed years.
The code 99Y will be used for patients 99 years old and older.
NOTE: If patient is between 1 and 9 years, enter Ø in column 27 to fill the field.
EXAMPLES:
7. AGE AT ADMISSION
27 28 29
1 8 Y
MD0753 4-16
7. AGE AT ADMISSION
27 28 29 NB
Ø Ø D
DESCRIPTION DATA CODES
Live-born infant ØØD

Less than 1 day ØØD
One day to less than 1 month Ø1D-3ØD
One month to less than 12 months Ø1M-11M
Patient's age in years, 1 year to 99 years 99Y
Patient's age is more than 99 years 99Y
Table 4-5. Age codes.
4-15. RACE (FIELD 8, COLUMN 30)
a. Source of data. Admission interview. (Item 6, ITRCS).
b. Enter the appropriate code from table 4-6.
EXAMPLE
8. RACE
30
C
Caucasoid (White) C
Negroid (Black) N
Mongoloid (Yellow) M
Western Hemisphere Indians (Red) R
Other X
Unknown Z
Table 4-6. Race codes.
NOTE: Do not use unknown (Z) for U.S. Army active duty personnel, Reserve/National
Guard or USMA cadets.
MD0753 4-17
4-16. ETHNIC BACKGROUND (FIELD 9, COLUMN 31)
a. Source of data. Admission interview.
b. Enter the appropriate data code and abbreviation from table 4-7. This is a
required field for all patients. The code z may be used for other than active duty
personnel.
EXAMPLE:
9. ETHNIC
BACK-
GROUND
31 OTHER
9
DESCRIPTION ABBREVIATION DATA CODE

Hispanic Hisp 1
SE Asian Se Asi 2
Filipino Filip 3
Other Asian/Pacific Islander Oth A/P 4
Other Oth 9
Unknown Unk z
Table 4-7. Ethnic background codes.
NOTE: Do not use unknown (Z) for U.S. Army active duty personnel, Reserve/National
Guard, or USMA cadets.
4-17. RELIGION
b. Enter the abbreviation for the patient's religious preference from table 4-8.
Leave blank for CRO cases.
MD0753 4-18
c. Table 4-8 is a partial list of religions. See AR 18-12-4 for a complete list.
EXAMPLE:
RELIGION
ROMAN-CATH
4-18. LENGTH OF SERVICE (FIELD 10, COLUMNS 32 THROUGH 34)
b. Enter the total length of all active duty service, even if interrupted, as of this
admission for U.S. military personnel, foreign military personnel, and uniformed services
military academy (USMA) cadets.
c. Show service as follows:
(1) Less than 1 month, record in days (e.g., 12 DYS on ITRCS will have data
code 12D on A&C Form).
DESCRIPTION DATA CODE
No Religious Preference (none) NO-REL-PREF

Adventist, Seventh-Day ADV-SEV-DAY
Assemblies of God ASBY-GOD
Baptist-American/Baptist Convention AMER-BAPT
Baptist-Southern/Baptist Convention SO-BAPT
Baptist-Other Groups BAPT-OTHER
Brethren/Dunkers BRETH
Buddhism BUD
Christian Science CHR-SCI
Church Of Christ CH-CHR
Church of God CH-GOD
Congregational Christian CONG-CHR
Disciples of Christ DIS-CHR
Episcopal/Anglican EPISC
Evangelical, United Brethren EVANG-U-BRETH
Evangelican and Reformed EVANG-REFMD
Friends/Quaker FRIENDS
Jehovah's Witnesses JEH-WIT
Table 4-8. Religion abbreviations (continued).
MD0753 4-19
Jewish JEWISH
Latter Day Saints/Mormon LAT-DAY-ST
Lutheran (excludes Lutheran, Missouri Synod) LUTH
Lutheran Missouri Synod LUTH-MO
Methodist (includes Evangelical United Brethren) METH
Evangelical Convenant EVANG-COV
Muslim MUSLIM
Nazarene NAZ
Orthodox ORTH
Orthodox-Russian ORTH-RUSS
Pentecostal PENT
Presbyterian PRESBY
Reformed REFMD
Roman Catholic ROMAN-CATH
Salvation Army SAL-ARMY
Unitarian Universalist UNITN-UNIV
United Church of Christ (excludes Congregational
Christian and Evangelical and Reformed) U-CH-CHR
Protestant-other churches PROT-OTHER
Protestant-no denominational preference PROT-NO- DENOM
Other religions OTHER-REL
Unknown UNK
Table 4-8. Religion abbreviations (concluded).
(2) Less than 1 year, record in months using completed months (e.g., 11
MOS on the ITRCS will have data code 11M on A&C Form).
(3) From 1 year to 40 years, record in years using completed years (e.g.,
service of 18 years and 9 months would have 18 YRS on ITRCS and data code 18Y on
A&C Form).
d. Enter the appropriate code from table 4-9. If days, months, or years of
service are less than 10, enter Ø in column 32. This is a required field for active duty.
For all other patients, leave this field blank.
EXAMPLE:
10. LENGTH OF SERVICE

32 33 34 2 MOS
Ø 2 M
MD0753 4-20
Entry on AD to 30 days ØØD-3ØD

One month AD, but less than 12 Ø1M-11M
Twelve months to 40 years AD Ø1Y-4ØY
Unknown ZZZ
Table 4-9. Length of service codes.
NOTE: Do not use unknown (ZZZ) for AD U.S. Army, Navy, Marine Corps, Air Force,
Reserve/National Guard or USMA cadets.
4-19. EXPIRATION OF TERM OF SERVICE (ETS)
b. Enter the date of ETS for military patients or the expiration date of Department
of Defense (DD) Form 1173, Uniformed Services Identification and Privilege Card for
dependent family members. For all other patients, leave this field blank.
EXAMPLE:
ETS17
NOV
9X
4-20. FAMILY MEMBER PREFIX (FMP) (FIELD 11, COLUMNS 35 THROUGH 36)
b. Enter the family member prefix (FMP) from table 4-10. This is a required field
for all patients and may not be zero-filled.
c. An eligible spouse (or eligible former spouse) and children are given an FMP
in the order that they become the sponsor's dependents. The sponsor's children
include those preadopted, adopted, legitimate, illegitimate, and stepchildren.
d. If a sponsor remarries, the new spouse takes the next higher number in the
thirty series; i.e., the first spouse is coded 3Ø and the second spouse is coded 31. A
former spouse eligible to deliver in a military MTF is coded in the 3Ø series, and the
newborn child is coded as beneficiary authorized by statute (9Ø-95).
MD0753 4-21
e. Former female service members eligible to deliver in a military MTF should be
coded as 2Ø, and the newborn child should be coded from the 9Ø-95 category.
Multiple births, belonging in this category, should be assigned 9Ø for the first, 91 for the
second, and so on.
f. The child of an unwed daughter of the sponsor is coded in the 9Ø-95 category,
unless the sponsor has adopted the child.
EXAMPLE:
11. FMP
35 36
2 Ø
Children (Oldest, Next Oldest, etc.) Ø1-19

Sponsor (Prime Beneficiary) 2Ø
Spouse & Former Spouses 3Ø -39
Mother or Stepmother 4Ø
Father or Stepfather 45
Mother-in-Law 5Ø
Father-in-Law 55
Other Authorized Dependents 6Ø-69
Beneficiary Authorized by Statute 9Ø-95
Civilian Emergencies 98
All Others, Not Elsewhere Classified 99
Table 4-10. Family member prefix (FMP) codes.
4-21. SOCIAL SECURITY NUMBER (SSN) (FIELD 12, COLUMNS 37 THROUGH 45)
a. Source of data. Admission interview or ID card. (Item 12, ITRCS).
b. Enter the SSN of the sponsor (active duty or retired service member,
deceased service member, reserve component service member, or other prime
beneficiary).
c. The sponsor's SSN will be used, with the appropriate family member prefix,
for identification of dependent family members, and all former spouses. When both
parents are active duty, children will be identified by the SSN of the mother. All
newborns will utilize the same SSN as coded on the mother's record.
MD0753 4-22
EXAMPLE:
12. SOCIAL SECURITY NUMBER
37 38 39 40 41 42 43 44 45
5 3 2 2 5 8 3 1 Ø
d. If the patient does not have an SSN, a pseudo-SSN will be constructed based
on the patient's date of birth using the following convention: 80 + 0-9, and the year,
month, and day (YYMMDD) of the patient's birth. The third digit (0-9) is used for
sequencing of multiple same birth date admissions. The patient in the example below is
the second admission with a birth date of 25 December 1969.
EXAMPLE:
12. SOCIAL SECURITY NUMBER

37 38 39 40 41 42 43 44 45
8 Ø 1 6 9 1 2 2 5
4-22. ORGANIZATION
b. Enter the active duty military patient's unit of assignment at the time of initial
admission or when CRO. Enter the next higher echelon of command only when the
designation of the unit is common to several organizations. Enter the unit and country
for foreign military patients.
EXAMPLE:
ORGANIZATION (Active Duty Only)
9 FLD HOSP FORT SAM HOUSTON, TX
MD0753 4-23
4-23. MARITAL STATUS (FIELD 13, COLUMN 46)
b. Enter the appropriate marital status data code from table 4-11. Use the
abbreviations in this table in the open space provided in field 13. This is a required field
for all patients.
EXAMPLE:
13. MARITAL STATUS

46
Annulled Ann A
Divorced Div D
Interlocutory Inter I
Legally Separated Sep L
Married Marr M
Single, Never Married Sing S
Widowed Wid W
Unknown Unk Z
Table 4-11. Marital status codes.
4-24. HOUR OF ADMISSION
a. Source of data. Self-explanatory. (Item 22, ITRCS).
b. Using the 2400-hour system enter the exact time the patient is admitted. For
newborns, enter the time of birth.
EXAMPLE:
HOUR OF
ADMISSION
Ø85Ø
MD0753 4-24
4-25. BRANCH/CORPS
b. Enter branch of service (Army, Navy, etc.) for enlisted personnel and other
service officers. Enter corps (MC, MS, IN, etc.) for active or retired Army officers.
Leave this area blank for all others.
EXAMPLES:
BRANCH/CORPS
ARMY
BRANCH/CORPS
BRANCH/CORPS
MS
4-26. FLYING STATUS (FIELD 14, COLUMNS 47 THROUGH 49)
a. Source of data. Admission interview. (Item 15, ITRCS)
b. For military patients on flying status, code Y for yes. For military patients not
on flying status, code N for no. Leave columns 48 and 49 blank.
c. For all other patients, leave this field blank.
EXAMPLE:
14. FLYING STATUS

47 48 49
MD0753 4-25
4-27. BENEFICIARY CATEGORY (FIELD 15, COLUMNS 50 THROUGH 52)
b. For U.S. Uniformed Services personnel (active or retired), enter the applicable
category from table 4-12 in the open space provided. When applicable, include "T" to
indicate AD for training or "I" to indicate inactive duty for training.
UNIFORMED SERVICE ABBREVIATION
Army (includes retired as well as Reserve and National

Guard on extended AD) ARMY
Army Reserve Initial AD for Training IADT
Other U.S. Army Reserve USAR
Other Army National Guard ARNG
U.S. Navy USN
U.S. Marine Corps USMC
U.S. Air Force USAF
U.S. Coast Guard USCG
U.S. Public Health Service PHS
National Oceanic and Atmospheric Administration NOAA
U.S. Military Academy Cadets USMA
U.S. Air Force Academy Cadets USAFA
U.S. Naval Academy Midshipmen USNA
Reserve Officers Training Corps ROTC
Table 4-12. Categories of Uniformed Services Personnel.
c. For civilian employees of Federal agencies, indicate the Federal department

(i.e., Army, Navy, State, Health and Human Services, Justice, Commerce, Labor,
Treasury).
d. For foreign military personnel, indicate the nation and armed forces with which
the patient is serving; such as Federal Republic of Germany, Army.
e. For all other personnel, leave the open space blank (no written description).
f. Enter the appropriate data code from table 4-13.
MD0753 4-26
EXAMPLE:
15. BENEFICIARY CATEGORY

50 51 52 ARMY
A 1 1
NOTE: Item 17, ITRCS will list the branch of service from which a patient was retired.
Item 13, ITRCS will list how the patient retired, (i.e., TDRL, PDRL, LENGTH OF
SERVICE).
Military
Extended Active Duty: (over 60 days)

Army A11
Navy N11
Marine Corps M11
Air Force F11
Coast Guard C11
U.S. Public Health Service P11
National Oceanic and Atmospheric Administration B11
AD Recruits: (less than 60 days)

Army A13
Navy N13
Marine Corps M13
Air Force F13
Coast Guard C13
Table 4-13. Department/type of beneficiary codes (continued).
MD0753 4-27
Reserves:
Army AD A12
IDT A22
Navy AD N12
IDT N22
Marine Corps AD M12
IDT M22
Air Force AD F12
IDT F22
Coast Guard AD C12
IDT C22
U.S. Public Health Service AD P12
IDT P22
National Guard:
Army AD A15
IDT A25
Air Force AD F12
IDT 23
Cadets:
USMA, West Point, NY A14
USNA, Annapolis, MD N14
USAFA, Colorado Springs, CO F14
USCGA, New London, CT C14
Army ROTC Cadet A21
Navy ROTC Cadet N21
Air Force ROTC Cadet F21
Other
Applicant/Registrant:
Army A26
Navy N26
Marine Corps M26
Air Force F26
MD0753 4-28
Former Service Members-Maternity Care Only:

Army A27
Navy N27
Marine Corps M27
Air Force F27
Coast Guard C27
Newborns of Former Service Members:

Army A28
Navy N28
Marine Corps M28
Air Force F28
Coast Guard C28
Retirees
Length of Service:
Army A31
Navy N31
Marine M31
Air Force F31
Coast Guard V31
U.S. Uniiformed Services Personnel on Permanent

Disability Retired List (PDRL):
Army A32
Navy N32
Marine Corps M32
Air Force F32
Coast Guard C32
MD0753 4-29
U.S. Uniformed Services Personnel on Temporary
Disability Retired List (TDRL):

Army A33
Navy N33
Marine Corps M33
Air Force F33
Coast Guard C33
Dependents
Dependents of AD Uniformed Services Personnel:

(Excludes Former Spouses)
Army A41
Navy N41
Marine Corps M41
Air Force F41
Coast Guard C41
Dependents of Retired U.S. Uniformed Services Personnel:

Army A43
Navy N43
Marine Corps M43
Air Force F43
Coast Guard C43
MD0753 4-30
Dependents of Deceased U.S. Uniformed Services Personnel:

Army A45
Navy N45
Marine Corps M45
Air Force F45
Coast Guard C45
Dependents of Deceased Retired Personnel:

Army A47
Navy N47
Marine Corps M47
Air Force F47
Coast Guard C47
Unremarried Former Spouse:

Army A48
Navy N48
Marine Corps M48
Air Force F48
Coast Guard C48
Dependents of Unremarried Former Spouse:

Army A49
Navy N49
Marine Corps M49
Air Force F49
Coast Guard C49
MD0753 4-31
U.S. Civilian Employees/Dependents:

State Department Employee-Overseas K51
State Department Dependent-Overseas K52
Other Federal Agencies/Department Employee K53
Other Federal Agencies/Department Dependent K54
DOD Remote Area Employee-CONUS K55
DOD Remote Area Dependent-CONUS K56
DOD Occupational Health K57
Disability Retirement Examination K58
Other K59
Other Beneficiaries of U.S. Government:

Veterans Administration (VA) K61
Office of Worker's Compensation (OWCP) K62
Service Home-Other Than Military Retiree K63
Other Federal Agencies/Departments K64
Contract Employee K65
Federal Prisoner K66
American Indian, Aleutian, Eskimo K67
Micronesian, Samoan, Trust Territories K68
Other K69
Foreign Nationals/Dependents:
IMET/SALES K71
NATO Military K72
NATO Dependent K73
Non-NATO Military K74
Non-NATO Dependent K75
Foreign Civilian K76
Foreign Civilian Dependent K77
Prisoner of War/Internees K78
Other K79
Defense Department Designee:
Secretary of Defense K81

Secretary of Army K82
Secretary of Navy K83
Secretary of Air Force K84
MD0753 4-32
Civilian, No Government Connection:
Humanitarian K91
Emergency K92
Patient Not Elsewhere Classified:
(Includes newborn of dependent daughter) K99
Table 4-13. Department/type of beneficiary codes (concluded).
4-28. ZIP CODE OF RESIDENCE (FIELD 16, COLUMNS 53 THROUGH 61)
b. Enter the nine-digit zip code of the patient's residence in continental United
States (CONUS). If the last four digits are unknown, zero-fill these positions. Outside
continental United States (OCONUS), the Army post office (APO) or fleet post office
(FPO) should be used.
c. This is a required field for all inpatient, CRO, and absent sick records. If the
zip code of residence is unknown, use the zip code of the MTF.
EXAMPLE:
16. ZIP CODE OF RESIDENCE

53 54 55 56 57 58 59 60 6
1
7 8 2 3 4 6 1 Ø Ø
4-29. UNIT LOCATION (FIELD 17, COLUMNS 62 THROUGH 63)
b. Enter the state or country code of AD patient's unit of assignment. Select the
state code from table 4-2. State codes, as well as overseas country location codes are
listed in the Individual Patient Data System (IPDS) User's Manual.
MD0753 4-33
c. For units operating outside of their home station, this is the deployed location
of operation. For soldiers not deployed with their unit, use the home base location. For
patients enroute to a permanent change of station (PCS), use the code of their last unit
of assignment.
d. This is a required field for AD, Reserve/National Guard, and USMA Cadets.
EXAMPLE:
17. UNIT LOCATION (State or

Country Code)
62 63 TEXAS
4 8
4-30. MILITARY OCCUPATIONAL SPECIALTY (MOS) CODE (FIELD 18, COLUMNS

64 THROUGH 70).
b. This field is for AD only. This is a required field for U.S. AD and
Reserve/National Guard personnel on active duty.
c. Enter the MOS code from the list of codes in Appendix F. Some codes for
U.S. Army occupational specialties are listed in this subcourse. A complete list for all
branches of military service can be found in the Individual Patient Data System (IPDS)
User's Manual.
d. This field is left-justified; do not zero-fill.
EXAMPLE:
18. MOS FOOD SVC SPEC

64 65 66 67 68 69 70
9 4 B
MD0753 4-34
4-31. TRAUMA (FIELD 19, COLUMN 71)
a. Source of data. Injury diagnosis, item 20 (type case), and item 33 (cause of
injury), ITRCS.
b. Enter a trauma code in field 19 from table 4-14.
c. A cause of injury code must be entered in field 35, and at least one of the
eight diagnostic fields must reflect an International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) injury diagnosis code from the 800 or 900
series, E930-E949, V71.3-V71.6, or 692.71.
EXAMPLE:
19. TRAUMA
71
3
Battle Wound or Injury

Direct Result of Action By or Against
an Organized Enemy (declared war only) Ø
Other Battle Casualties 1
Intentionally Inflicted Nonbattle Injury

Result of Intervention of Legal Authority 2
Assault or Intentionally Inflicted By Another Person 3
Intentionally Self-Inflicted 4
Accidental Injury (use codes 5-8 for AD only)

Occurring While Off Duty (Includes leave, pass, absent 5
without leave (AWOL), and other off-duty
Schemes (Maneuvers) and Exercises 6
All Other Scheduled Training (Including basic training, 7
assault courses, etc)
Occurring While On Duty (Except as in 6 and 7 above) 8
Unknown Whether On or Off-Duty and Nonmilitary Injuries 9
(use for all patients)
Table 4-14. Trauma codes.
MD0753 4-35
4-32. PREVIOUS ADMISSION
b. Check "No" if the patient has not been admitted to your facility before. This
entry is to indicate existence of a record of previous treatment in your MTF. Enter the
year of previous admission if the patient has been admitted to your MTF whether for the
same condition or for any other condition.
EXAMPLE:
PREV ADMISSION
YEAR _ NO
4-33. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION (FIELD 20,

COLUMN 72)
a. Source of data. Admission interview or ID card. Item 21, ITRCS for transfers.
b. Enter "Dir" for direct admission from other than the emergency room.
c. Enter "Dir-ER" for direct admission from the ER.
d. Enter "Trnsf" when the patient has been transferred from any other facility.
e. Enter "CRO" for carded for record only cases.
f. Enter "NB" for liveborn infants delivered in your MTF.
g. Include the applicable authority for admission paragraphs from AR 40-3.
h. Select the appropriate data code from table 4-15.
MD0753 4-36
EXAMPLE:
20. SOURCE OF ADMISSION/AUTHORITY FOR

ADMISSION
72 DIR FROM ER
AR 4Ø-3 PARA 4-1
Ø
Direct to Military Hospital from ER Ø

Direct to military hospital from other than ER 1
AD direct to non-U.S. Armed Services hospital never
transferred to military hospital 3
Initial admission in non-U.S. Armed Services hospital,
transferred to militay 9 AD only) 4
Initial admission to non-U.S. Armed Services hospital,
moved to military hospital (non-AD only) 5
Transfer from U.S. Army hospital 6
Transfer from U.S. Navy hospital 7
Transfer from U.S. Air Force hospital 8
Live birth in this hospital L
CRO C
Table 4-15. Source of admission.
4-34. WARD
a. Source of data. Designated by care provider/physician.
b. Enter the ward or nursing unit to which the patient was admitted. Leave blank
for CRO cases. Enter "Abs Sk" for AD patients never transferred to a military hospital
and whose entire period of hospitalization was in a non-U.S. Armed Services hospital.
MD0753 4-37
EXAMPLES:
WARD
12B
WARD
ABS SK
4-35. EMERGENCY ADDRESSEE
a. Source of data. Admission intervew. (Items 24, 27, and 29, ITRCS).
b. Enter information relating to emergency addressee. Leave blank for CRO

cases.
EXAMPLE:
NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE

JOHN R. DALLAS/FATHER
ADDRESS OF EMERGENCY ADDRESSEE (Include Zip Code)
222 PRUNE STREET, FLINT MI 48504
TELEPHONE NUMBER OF EMERGENCY ADDRESSEE
(543) 214-7909
4-36. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY (MTF)
a. Source of data. Self-explanatory (your MTF).
b. Enter the name and location of the reporting MTF.
MD0753 4-38
EXAMPLE:
NAME AND LOCATION OF MEDICAL TREATMENT FACILITY

USAH, FORT SPLENDID, TX
4-37. TYPE OF DISPOSITION (FIELD 21, COLUMNS 73 THROUGH 74)
a. Source of data. The AAD office. (Item 25, ITRCS).
b. Enter the type of disposition of the patient (e.g., Duty, Transfer, Died,
Discharged Home).
c. Enter the appropriate data code from table 4-16.
d. Use the disposition code "50" (CRO-Other) for stillbirths delivered outside
your MTF and subsequently brought to the MTF for disposition of remains and for
selected conditions of medical, legal, or other significance for which inpatient treatment
is not required.
EXAMPLE:
21. TYPE OF
DISPOSITION
73 74 DIED
3 Ø
Active Duty Patients and Separations

Returned to duty Ø1
To Duty from TDRL (includes CRO) Ø2
To PDRL from TDRL (includes CRO) Ø3
AWOL (dropped from rolls) Ø4
Separation/Retired--PDRL (includes CRO) 1Ø
Separation/Retired--TDRL (includes CRO) 11
Table 4-16. Disposition type codes (continued).
MD0753 4-39
Active Duty Patients and Separations
Separation W/Severance pay (includes CRO) 12

Separation WO/Severance pay (includes CRO) 13
Nondisability separation for drug/alcohol abuse at or 14
after transfer or referral to NON-U.S. Armed Service MTF
Separation for failure to meet medical procurement standards 15
(includes CRO)
Transferred--Army MTF 21
Transferred--Navy MTF 22
Transferred--Air Force MTF 23
Discharged to other Federal facility (includes VA, Indian 24
Health Service (IHS), excludes Army MTF, Navy MTF or
Air Force MTF)
Died during inpatient stay 3Ø
CRO--Dead on Arrival (DOA) 41
CRO--ER Death 42
CRO--Other 5Ø
CRO--Killed in action (KIA) 51
Non-AD Patients
Discharged Home Ø5
Left against medical advice (AMA) Ø6
Transferred--Army MTF 21
Transferred--Navy MTF 22
Transferred--Air Force MTF 23
Discharged to other Federal facility (includes VA, IHS; 54
Excludes Army MTF, Navy MTF, Air Force MTF)
Discharged to civilian hospital, nursing home, convalescent 25
Center
Died during inpatient stay 3Ø
CRO--Dead on Arrival (DOA) 41
CRO--ER Death 42
CRO--Other 5Ø
Table 4-16. Disposition type codes (concluded).
MD0753 4-40
4-38. MTF TRANSFERRED TO (FIELD 22, COLUMNS 75 THROUGH 80)
b. Enter the code for the MTF to which the patient is being moved. Locate a first
position code from table 4-17, followed by the MTF code from table 4-1. A complete list
of MTF codes can be found in the Individual Patient Data System (IPDS) User's Manual.
c. If the transfer is to other than a U.S. military MTF, construct a three-position

code. Locate a first position code from table 4-17. The second and third positions will
either be a two-numeric state code from table 4-2, or a two-alpha character country
code, or local civilian facilities may be assigned a number by your facility for catchment
area management. The entire code should be no more than six characters and left-
justified. If positions 4, 5, and 6 are not coded for use at the local level, leave blank.
d. In the following examples, the first patient was transferred to a civilian MTF in
the state of Massachusetts; the second patient was transferred to Fitzsimons AMC,
Denver CO.
EXAMPLES:
22. MTF TRANSFERRED TO

75 76 77 78 79 80
C 2 5
22. MTF TRANSFERRED TO

75 76 77 78 79 80
A 1 2 Ø 1
MD0753 4-41
Military Medical Treatment Facility

Army MTF A
Navy MTF N
Air Force MTF F
Non-U.S. Military Medical Treatment Facility
Civilian MTF C
Veterans Administration MTF V
Public and Indian Health MTF P
Foreign Military MTF M
Other MTF B
Table 4-17. First position MTF codes.
4-39. DATE OF DISPOSITION (FIELD 23, COLUMNS 81 THROUGH 86)
a. Source of data. Self-explanatory.
b. Enter the date of the patient's disposition from your MTF. If you have
administrative responsibility for a patient in a civilian MTF (i.e., absent sick), enter the
date the patient was removed from the census of the civilian MTF. Enter the same date
as the "Date of this Admission" for a CRO case.
EXAMPLE:
EXAMPLE: 23. DATE OF DISPOSITION

(YYMMDD)
81 82 83 84 85 86 29
JAN 9X
9 X Ø 1 2 9
MD0753 4-42
4-40. CLINIC SERVICE - ADMITTING (FIELD 24, COLUMNS 87 THROUGH 9Ø)
a. Source of data. Designated by care provider/ physician. (Item 23, ITRCS).
b. The mission of the MTF will determine the clinic services established in your
facility. Enter the code from table 4-18 for the initial clinic service to which the patient is
assigned upon admission.
c. Leave the field blank for absent sick patients whose entire period of
hospitalization was spent in that status and for CRO cases. For patients in a
cooperative care or supplemental care status, use the code of the clinic service referring
the patient to the civilian facility.
d. If one of the following programs is applicable, change the fourth digit from "A"
to one of the following codes:
(1) E - Exceptional Family Member Program (EFMP).
(2) O - Catchment Area Management Programs.
(3) P - Partnership Programs.
(4) R - Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS) Reform Initiatives.
(5) S - CRI/Resource Sharing Programs.
(6) U - Alternate Use/CHAMPUS Funds.
NOTE: Do not use the codes above for CRO (XXXA) and Absent Sick (YYYA).
EXAMPLE:
24. CLINIC SVC - ADMITTING

87 88 89 90 GEN
SURG
A B A A
MD0753 4-43
Clinic Service
Adolescent Pediatrics Adol Ped ADDA

Allergy Algy AASA
Bone Marrow Transplant Marr Trans AAQA
Cardiology Cardio AABA
Cardiovascular/Thoracic Surgery Cv/Thor Surg ABBA
Clinical Immunology Cl Immu AAOA
Coronary Care Unit CCU AACA
Dermatology Derm AADA
Endocrinology Endocrn AECA
Gastroenterology Gastro ABPA
General Surgery Gen Surg ABAA
Gynecology GYN ACAA
Hand Surgery Hand Surg AECA
Head and Neck Surgery Hd/Nk Surg ABPA
Hematology Hem AAGA
Human Immunodeficiency Virus (HIV)
III, Acquired Immune Deficiency
Syndrome (AIDS) Referral Center HIV AAPA
Infectious Disease Inf Dis AARA
Institute of Surgical Research
(Burn Center, Brooke Army
Medical Center (BAMC) only) ISR ABMA
Internal Medicine Int Med AAAA
Medical Intensive Care Unit MICU AAHA
Neonatal Intensive Care Unit NICU ADCA
Table 4-18. Medical Expense and Performance Reporting System (MEPRS)

clinic service codes (continued).
MD0753 4-44
Nephrology Nephro AAIA

Neurology Neuro AAJA
Neurosurgery Neuro Surg ABDA
Nursery Nsy ADBA
Obstetrics OB ACBA
Oncology Oncol AAKA
Ophthalmology Ophth ABEA
Oral Surgery Oral Surg ABFA
Organ Transplant, Walter Reed
Army Medical Center (WRAMC) Org Trans ABLA
Orthopedics Ortho AEAA
Otorhinolaryngology ENT ABGA
Pediatrics Ped ADAA
Pediatric Surgery Ped Surg ABHA
Peripheral Vascular Surgery PV Surg ABNA
Physical Medicine Phys Med AANA
Plastic Surgery Plas Surg ABIA
Podiatry Pod AEBA
Proctology Procto ABJA
Psychiatry Psy AFAA
Pulmonary/Upper Respiratory Disease Pulm Dis AALA
Rheumatology Rheum AAMA
Substance Abuse Rehabilitation SA Rehab AFBA
Surgical Intensive Care Unit SICU ABCA
Trauma Center Trau Ctr ABOA
Urology Urol ABKA

clinic service codes (continued).
MD0753 4-45
Family Practice (FP)

FP Gynecology FP GYN AGEA
FP Medicine FP Med AGAA
FP Nursery FP Nsy AGHA
FP Obstetrics FP OB AGCA
FP Orthopedics FP Ortho AGGA
FP Pediatrics FP Ped AGDA
FP Psychiatry FP Psy AGFA
FP Surgery FP Surg AGBA
Carded for Record Only CRO XXXA
Absent Sick Abs Sk YYYA

clinic service codes (concluded).
4-41. MTF TRANSFERRED FROM (FIELD 25, COLUMNS 91 THROUGH 96)
b. Enter the code for the MTF from which the patient was received. Locate a first
position code from table 4-17, followed by the MTF code from table 4-1.
c. If the transfer is from other than a U.S. military MTF, construct a three-position
code. Use the same coding procedure as in MTF transferred to (field 22).
d. In the fo llowing example, the patient was transferred from a foreign military
MTF in the United Kingdom.
EXAMPLE:
25. MTF TRANSFERRED FROM

91 92 93 94 95 96
M U K
MD0753 4-46
4-42. DATE OF THIS ADMISSION (FIELD 26, COLUMNS 97 THROUGH 102)
a. Source of data. AAD office. (Item 28, ITRCS).
b. Enter the date of the patient's actual admission to your MTF.
c. For AD Army personnel with entire hospitalization in an absent sick status

(source of admission data code 3), leave this field blank. For AD Army personnel who
are change-of-status in to your MTF (source of admission data code 4), enter the date
of the change-of-status.
d. For CRO cases, enter the date of notification or preparation of record. Enter
the actual date of treatment, if it is different from notification/preparation in item 31,
ITRCS.
e. For transfer admissions, enter the date the patient arrived at your MTF.
EXAMPLE:
26. DATE OF THIS ADMISSION (YYMMDD)

97 98 99 100 101 102 8 JAN
9X
9 X Ø 1 Ø 8
4-43. LOCATION OF OCCURRENCE (FIELD 27, COLUMNS 103 THROUGH 104)
b. Enter state codes from table 4-2 or country location codes (located in the
IPDS User's Manual) to indicate geographical location for all patients treated during
deployment. The receiving MTF for a transfer case must record the original location of
occurrence code.
NOTE: The directive to use this field for "Battle Casualty Only" was rescinded in
November 1990. This field may be used for all cases.
MD0753 4-47
EXAMPLE:
27. LOCATION OF OCCURRENCE

103 104 (Battle Casualty Only)
SAUDI ARABIA
S A
4-44. MTF OF INITIAL ADMISSION (FIELD 28, COLUMNS 105 THROUGH 110)
a. Source of data. Admissions office and Item 31, ITRCS.
b. Leave this field blank for direct admissions to your MTF.
c. For transfer admissions, enter the code for the first MTF to which the patient
was admitted for the current episode of illness/ injury. Locate a first position code from
table 4-17, followed by the MTF code from table 4-1. A complete list of MTF codes can
be found in the Individual Patient Data (IPDS) User's Manual.
d. If the initial admission was to other than a U.S. military MTF, construct a
three-position code. Locate a first position code in table 4-17. The second and third
positions will either be a two-numeric state code from table 4-2, or a two-alpha
character country code, or local civilian facilities may be assigned a number by your
facility for catchment area management. The entire code should be no more than six
characters and left-justified.
e. For Army hospitals not listed in this document or the IPDS user's manual,
contact PASBA, Medical Summary Branch, DSN 471-5579 for the codes.
f. In the following examples, one patient was initially admitted to JTF-B Med El in
Honduras; another was initially admitted to an Indian Health Service hospital in North
Dakota.
MD0753 4-48
EXAMPLES:
28. MTF OF INITIAL ADMISSION

105 106 107 108 109 110 JTF HONDURAS
A Ø 1 K 1
28. MTF OF INITIAL ADMISSION

105 106 107 108 109 110 IHS,
NORTH DAKATO
P 3 8
4-45. DATE OF INITIAL ADMISSION (FIELD 29, COLUMNS 111 THROUGH 116)
a. Source of data. Medical records accompanying the transfer patient or absent

sick notification.
b. Enter the date when first admitted for this continuous period of hospitalization
for total absent sick cases, transfer patients, and those admitted from absent sick
status. Leave blank for all other cases.
EXAMPLE:
29. DATE OF INITIAL ADMISSION (YYMMDD)

111 112 113 114 115 116 19 FEB 9X
9 X Ø 2 1 9
MD0753 4-49
4-46. FOR LOCAL USE.
The reporting MTF will determine entries made in this area.
EXAMPLE:
FOR LOCAL USE
FX HUMERUS, OPEN TRIPPED AND FELL ON RT

OPEN REDUCTION WITH ARM IN HOME AT 1400
INTERNAL FIXATION DEVICE ON DATE OFADMISSION
4-47. ADMITTING OFFICER
b. Enter the name of the physician or other care provider authorizing admission.
If the A&C Form is used as the admission authorization, the admitting officer should
sign in this area.
EXAMPLE:
ADMITTING OFFICER (Signature, as required)
Ellis P. Brewster, COL, MC
4-48. SIGNATURE OF ADMITTING CLERK
b. The admitting clerk should sign in this area.
MD0753 4-50
EXAMPLE:
SIGNATURE OF ADMITTING CLERK
IMA CLARK
NOTE: You will now begin coding page 2, DA Form 2985.
4-49. AGE AT DISPOSITION (FIELD 30, COLUMNS 117 THROUGH 119)
a. Source of data. Calculated in AQCESS/CHCS. For nonautomated sites,

AAD office.
b. For live births and transferred live births with ØØD (age at admission) in field
7, age will be the actual number of days from birth to disposition.
c. Nonautomated sites should add a year or more as appropriate if the patient

has had a birthday(s) during this period of hospitalization.
d. Enter the patient's age in completed days, months, or years at the time of this
disposition. Select the appropriate code from table 4-5. If days, months, or years of
age are less than 10, enter a zero in the first position (i.e., Ø8M). If the patient is 1 year
old or older, enter the age in completed years except that the code "99Y" will be used
for patients 99 years or older.
EXAMPLE:
30. AGE AT DISP

117 118 119
1 8 Y
MD0753 4-51
4-50. AUTOPSY (FIELD 31, COLUMN 120)
a. Source of data. Patient's clinical record, items 25 and 31, ITRCS.
b. Enter "Y" for yes and "N" for no to indicate whether or not an autopsy was
performed. An entry is required for all death cases including CRO. For other than
death cases, leave this field blank .
EXAMPLE:
31. AUTOPSY
120 Y/N
4-51. UNDERLYING CAUSE OF DEATH/SEPARATION (FIELD 32, COLUMN 121)
a. Source of data. Item 34, ITRCS.
b. This code indicates which of the eight diagnostic fields identifies the cause of
death in both inpatient deaths and CRO cases. Select the data code (1 through 8) from
table 4-19.
c. Separations from service for disability.
(1) For injury cases, select the data code (1 through 8) from table 4-19 that
identifies the field in which the underlying cause of disability for current injury is coded.
A code for residual disability is required in field 33.
(2) For disease cases, select the data code (1 through 8) from table 4-19 that
identifies the field in which the principal disabling disease is coded. No residual
disability code is required for disease cases.
d. For separation from service for failure to meet medical procurement

standards, select data code (1 through 8) from table 4-19 that identifies the field in
which the principal cause of separation is coded. No residual disability code is required.
MD0753 4-52
EXAMPLE:
32. UNDERLYING CAUSE

121 OF DEATH/SEP
e. The underlying cause of death or principal cause of separation/retirement, or

the principal cause for failure to meet medical fitness standards appears in the field
indicated by the data code in the following table.
Field 36 1
Field 37 2
Field 38 3
Field 39 4
Field 40 5
Field 41 6
Field 42 7
Field 43 8
Table 4-19. Underlying cause of death/separation codes.
4-52. RESIDUAL DISABILITY (FIELD 33, COLUMNS 122 THROUGH 124)
Leave this field blank. Residual disability collection has been discontinued.
4-53. DATA FILLER (FIELD 34, COLUMNS 125 THROUGH 133)
Leave this field blank. This field is reserved for future use.
4-54. CAUSE OF INJURY (FIELD 35, COLUMNS 134 THROUGH 136)
b. Enter a cause of injury code for any injury diagnosis (codes 8000 to 9999,
692.71, V71.3 to V71.6, and E9300 to E9499) appearing in diagnostic fields 36 to 43
MD0753 4-53
on the A&C Form. If more than one injury diagnosis is recorded in fields 36-43, enter a
cause of injury code in field 35 for the first injury.
c. External cause of injury STANAG code structure. The three digits of the code
provides identification of specific causative agents with 12 broad categories, along with
additional information on the place of occurrence for categories VIII through XII. The 12
broad categories are as follows:
I ØØØ-Ø59 Accidents in air transport, as specifically defined;

spacecraft accidents and escape system injuries.
II 1ØØ-149 Accidents in land transport, as specifically defined.
III 15Ø-199 Accidents in water transport, as specifically defined.
IV 2ØØ-249 Athletics and sports.
V 25Ø-299 Reactions, complications, and misadventures in medical

or surgical procedures; and late complications or late effects.
VI 3ØØ-479 Instrumentalities of war, when employed by the enemy in

wartime.
VII 48Ø-499 Accidents in connection with own instrumentalities of

war when employed as such in wartime.
VIII 5Ø-59* Guns, explosives, and related agents except when used
as instrumentalities of war in wartime.
Ix 60*-60* Machinery, tools, and selected agents.
X 70*-79* Poisons, fire, hot or corrosive substances.
Xi 80*-89* Specified environmental factors (natural or artificial environment).
Xii 9Ø*-99* Falls and miscellaneous other or unspecified agents.
*Third digit is place of occurrence code.
d. Transport accidents. The first three categories of the causative agent codes
include mishaps which are defined as transport accidents on land, in air, or in water.
MD0753 4-54
The mishap must have occurred during the use of these means of transport and that
occurrence must have been a result of the hazards related to such use (i.e., a fall
aboard ship would not be considered a hazard related to transport by ship). The use is
considered to have begun when personnel board for the purpose of transport.
e. Place of occurrence. Categories VIII to XII require the use of standard third-
digit "place of occurrence" codes (see table 4-20). In the following example, the patient
was assaulted by an unknown person at the barracks. The first and second positions
(97) are for the external cause of injury. The third-digit position (8) indicates the place
of occurrence.
EXAMPLE:
35. CAUSE OF INJURY

134 135 136
9 7 8
PLACE OF OCCURRENCE OF INJURY DATA CODE
Onboard aircraft, spacecraft, in the air Ø

or in space
Onboard ship, other water transport, or in water/sea, 1
river, lake, etc.
On land and at an airfield 2
On land and at a dock 3
On land and at an industrial plant (e.g., ordnance 4
factory, supply warehouse, repair shop)
On land and on firing range, or drill field 5
On land and on obstacle course 6
On land and in kitchen (other than home), 7
mess hall, or bakery
On land and in the home, quarters, or barracks 8
On land, other, or unspecified 9
Table 4-20. Place of occurrence of injury third-digit codes.
MD0753 4-55
4-55. DIAGNOSTIC CODING (FIELDS 36 TO 43, COLUMNS 137 THROUGH 200)
b. Use the ICD-9-CM, Volumes 1 and 2, to code the diagnosis(es). Coding rules
and principles are outlined in the Triservice Disease and Procedure Coding Guidelines,
dated 1 January 1991.
c. There are eight diagnostic fields. If there are fewer than eight diagnoses
recorded on the ITRCS, leave unused fields blank. If there are more than eight
diagnoses recorded on the ITRCS, use the following priorities to select only eight:
(1) Select the principal diagnosis. The condition established by medical

examinations and tests to be the primary reason for the patient's admission is the
principal diagnosis and will be coded in field 36. When there are two or more diagnoses
of equal importance present on admission, and when the medical record documentation
does not indicate otherwise, the principal diagnosis is the one for which a definitive
surgical or nonsurgical procedure was performed. If no definitive procedure was
performed, any one of the diagnoses may be principal.
(2) Select and record complications and/or co-morbidities.
(3) Record diagnosis(es) relating to therapeutic procedures.
(4) Record the underlying cause of death or cause of disability

retirement/separation.
(5) Select etiology codes prior to manifestation codes.
(6) Select the remaining diagnoses which contributed most to prolonged

hospitalization after recording diagnoses based on the above priorities.
d. Use the first three/four/five columns in the diagnostic fields for ICD-9-CM
codes. Do not zero-fill to the fourth column for three-digit codes. Leave the fifth column
blank for four-digit codes.
e. Leave the sixth column blank. This column is reserved for future use.
f. Use the seventh column for DOD diagnostic code extenders. The codes that
require an extender are listed in Appendix A, Triservice Disease and Procedure Coding
Guidelines, dated 1 January 1991. (See Coding Principles, Appendix A of this
subcourse.)
MD0753 4-56
g. Enter a code from table 4-21 in the eighth column to indicate where the
diagnostic condition was treated or managed.
EXAMPLES:
36. FIRST DIAGNOSIS (Principal Diagnosis)

137 138 139 140 141 142 143 144
8 6 5 Ø Ø Ø
37. SECOND DIAGNOSIS

145 146 147 148 149 15Ø 151 152
8 2 1 1 1 Ø
PLACE OF TREATMENT DATA CODE
Condition treated at or managed in reporting MTF Ø

CRO cases and admission source 3 Z
(cases treated entirely in absent sick status)
V27 diagnosis only--delivered at a civilian hospital C
Table 4-21. Place of treatment codes.
NOTE: V27 diagnosis (outcome of delivery) may be coded with Ø, Z, or C. All other
diagnoses may be coded with Ø or Z.
4-56. PROCEDURE CODING (FIELDS 44 TO 51, COLUMNS 201 THROUGH 264)
b. Use ICD-9-CM, Volumn 3, to code the procedures. Coding rules and

principles are outlined in the Triservice Disease and Procedure Coding Guidelines,
dated 1 January 1991.
MD0753 4-57
c. There are eight procedure fields. If there are less than eight procedures
recorded on the ITRCS, leave the remaining fields blank. If there are more than eight
procedures recorded on the ITRCS, select only eight, using the following priorities:
(1) Record the principal procedure first, in field 44. The principal procedure
is the one performed for therapeutic rather than for diagnostic or exploratory purposes
or to treat a complication.
(2) Record procedures performed for underlying causes of death or disability

retirement/separation.
(3) Record the more significant procedures remaining that are related to
conditions causing prolonged hospitalization or those which have special interest to the
staff.
d. Each procedure field has eight columns. Use the first three/four columns of
each procedure field for the ICD-9-CM procedure code. For three-digit codes, do not
zero-fill to the fourth column.
e. Leave the fifth column blank. This column is reserved for future use.
f. Use the sixth position to indicate where the procedure was performed. Enter a
code from table 4-22.
g. Enter a code, Ø1 to 99, in the seventh and eighth columns to indicate the
number of times a procedure was performed at the reporting MTF during the current
period of hospitalization.
EXAMPLE:
44. FIRST PROCEDURE (Principal Diagnosis)

201 202 203 204 205 206 207 208
4 1 5 D Ø 1
45. SECOND PROCEDURE

209 210 211 212 213 214 215 216
7 9 3 6 D Ø
MD0753 4-58
PLACE OF PERFORMANCE OF PROCEDURE DATA CODE
This MTF, not CRO patient D

This MTF, CRO patient R
Same Day Surgery Program X
Nonhospital facility T
Civilian hospital C
Another federal facility during current hospitalization this MTF (not
for procedures performed prior to transfer admission) J
Table 4-22. Surgical procedures place of performance codes.
4-57. NUMBER OF DIAGNOSTIC FIELDS CONTAINING CODES (FIELD 52,

COLUMNS 265 THROUGH 266)
b. Total is system generated by AQCESS/CHCS. For nonautomated sites, enter

the total number of fields used to code the patient's diagnosis(es).
c. This field is right-justified and zero-filled to the left.
EXAMPLE:
52. NUMBER OF DIAGNOSTIC FIELDS

265 266 CONTAINING CODES
Ø 3
4-58. NUMBER OF PROCEDURAL FIELDS CONTAINING CODES (FIELD 54,

COLUMNS 269 THROUGH 271)
b. Total is system-generated by AQCESS/CHCS. For nonautomated sites, enter

the total number of fields used to code any procedures the patient has undergone.
c. This field is right-justified and zero-filled to the left.
MD0753 4-59
EXAMPLE:
53. NUMBER OF PROCEDURAL FIELDS

267 268 CONTAINING CODES
Ø 3
4-59. PRIMARY PROVIDER SPECIALTY CODE (FIELD 54, COLUMNS 269

THROUGH 271)
a. Source of data. The AAD office.
b. This is an optional field for U.S. Army facilities. The code is system generated
by AQCESS/CHCS. Nonautomated sites should select a code from Appendix F,
Individual Patient Data System (IPDS) User's Manual if your MTF chooses to code this
field. In the following example, the specialization of the primary provider is general
surgeon.
EXAMPLE:
54. PRIMARY PROVIDER

269 270 271 SPECIALTY CODE
1 Ø Ø
4-60. BLOOD USAGE (FIELD 55, COLUMN 272)
a. Source of data. System-generated by AQCESS/CHCS if the blood utilization

screen is completed. If the screen is not completed and for nonautomated sites, Item
32, ITRCS.
b. Enter "Y" for yes, blood or blood components was transfused. If no blood or
blood components was transfused, enter "N" for no. In the following example the
patient received 4 units of blood.
MD0753 4-60
EXAMPLE:
55. BLOOD USAGE

272 Y/N
NOTE: You will now begin coding page 3, DA Form 2985. Nonautomated sites
should enter the code from page one for the Reporting MTF and the patient's
register number.
4-61. TOTAL SICK DAYS ALL FACILITIES (FIELD 56, COLUMNS 273
THROUGH 277)
a. Source of data. This field is automatically computed by AQCESS/CHCS

based on transactions processed in AAD. For nonautomated sites, this is the
number of days between the date of initial admission and the date of disposition
from your facility.
b. Patient days entered in this field represent total days to date at all
facilities. However, sick days in a civilian facility are counted for AD personnel only.
(1) Direct, Absent Sick. Enter the number of days between date of initial
admission and the date of disposition. (Using a Julian calendar, subtract the day of
disposition from the day of initial admission.) This number should equal the total
number of sick days this MTF (field 67) plus the number of sick days at all other
facilities (fields 58-59).
(2) Total Absent Sick. Enter the number of days between date of initial
admission and date of disposition. (Using a Julian calendar, subtract the day of
disposition from the day of initial admission). There is no "date of this admission"
on this record. This number should be the same as the number in field 67.
(3) Carded for Record Only (CRO). Enter "Ø" days in this field as well as
in field 67 and all other field requiring the number of sick/bed days for CRO cases.
(4) Direct Admission. Enter the number of days between date of this
admission and date of disposition. (Using a Julian calendar, subtract the day of
disposition from the day of this admission.) For a direct admission and final
MD0753 4-61
disposition on the same date, enter ØØØØ1. For a direct admission with "transfer"
disposition on the same date, enter ØØØØØ. These totals should be the same as
the entry in field 67.
(5) Admission by Transfer. Enter the number of days between date of

initial admission and date of disposition. (Using a Julian calendar, subtract the day
of disposition from the day of initial admission.) This total should be the sum of the
sick days at your MTF in field 67 and plus sick days at all other facilities. For a case
transferred in and dispositioned by transfer on the same date, enter the total for all
other facilities. Your MTF gets ØØØØØ sick days. For a transfer case with final
disposition on the same date, your facility gets ØØØØ1 sick day. Enter the sum of
one sick day at your facility plus the total number of days at all other facilities.
EXAMPLE:
56. TOTAL SICK DAYS (ALL FACILITIES)

273 274 275 276 277
Ø Ø Ø 2 1
4-62. BED DAYS THIS MTF (FIELD 57, COLUMNS 278 THROUGH 281)

based on transactions processed in AAD. Items 35F or 36F, ITRCS for nonautomated
sites.
b. For nonautomated sites:
(1) Enter the total days the patient occupied a bed in your facility. A patient
on pass for periods not exceeding 72 hours will be considered as occupying a bed
during that period.
(2) Days that a patient was in an absent status will not be counted as bed
days this MTF.
(3) Days that a patient spent in the labor or delivery room and neonatal
intensive care nursery will be counted as bed days in this MTF. Days spent by a
newborn in the newborn nursery will be counted as bassinet days.
(4) A bed day is also counted when a patient is admitted and dispositioned
(final disposition) on the same day.
MD0753 4-62
(5) Bed days this MTF is the difference between the number of total sick
days this MTF (field 67) minus the total of any days in fields 58 to 66.
EXAMPLE:
57. BED DAYS THIS MTF

278 279 280 281
Ø Ø 2 1
4-63. BED DAYS OTHER FEDERAL MTFS (FIELD 58, COLUMNS 282 THROUGH
285)

based on transactions processed in AAD. Items 21 and 31, ITRCS for nonautomated
sites.
b. For nonautomated sites, enter the total number of days spent in other Federal
MTFs during this period of hospitalization. Patients must be in a status-out to another
Federal facility (source of admission 6, 7, or 8). In the following example, the patient
was hospitalized for 3 days in another Federal MTF before transfer to your MTF.
EXAMPLE:
58. BED DAYS OTHER FED MTFS

282 283 284 285
Ø Ø Ø 3
4-64. BED DAYS CIVILIAN HOSPITALS (FIELD 59, COLUMNS 286 THROUGH 289)

based on transactions processed in AAD. For nonautomated sites, Items 21 and 31,
ITRCS.
b. The source of admission (field 20) for the patient must be absent sick.
c. For a patient initially absent sick in a civilian facility and subsequently moved
to your MTF, the absent sick civilian bed days will be the difference between the date of
initial admission and the date of this admission. Using a Julian calendar, subtract
day of this admission from day of initial admission.
MD0753 4-63
d. Enter the total number of absent sick civilian bed days during the period for
which your MTF had administrative control of the AD Army patient. In the following
example, the patient was initially absent sick in a civilian MTF on 7 March 199X
(Julian day 066) and admitted to your MTF on 9 March 199X (Julian day 068).
EXAMPLE:
59. BED DAYS - CIV HOSPITALS

286 287 288 289
Ø Ø Ø 2
4-65. BASSINET DAYS (NEONATAL) (FIELD 60, COLUMNS 290 THROUGH 293)

based on transactions processed in AAD. For nonautomated sites, the source of
admission must be a live birth at your facility.
b. For nonautomated sites, enter the number of days that a live-born resides in a
newborn nursery. Do not include those "newborns" born outside of your facility and
subsequently admitted. Do not include days spent in the neonatal intensive care
nursery.
EXAMPLE:
60. BASSINET DAYS - (NEONATAL)

290 291 292 293
Ø Ø Ø 3
MD0753 4-64
4-66. QUARTERS DAYS (FIELD 61, COLUMNS 294 THROUGH 297).
This field is not used.
EXAMPLE:
61. QUARTERS DAYS

294 295 296 297
4-67. MEDICAL HOLDING DAYS (FIELD 62, COLUMNS 298 THROUGH 301)

based on transactions processed in AAD. For nonautomated sites, patients must be in
a status-out to medical hold in AAD to accrue days in this category.
b. For nonautomated sites, enter the total number of days spent by AD service
members assigned to the medical holding unit/ward.
EXAMPLE:
62. MEDICAL HOLDING DAYS

298 299 300 301
Ø Ø 1 6
4-68. COOPERATIVE CARE DAYS (FIELD 63, COLUMNS 302 THROUGH 305)

based on transactions processed in AAD. Patients must be in a status-out to
cooperative care in AAD in order to accrue days in this category. For nonautomated
sites, Item 31, ITRCS.
MD0753 4-65
b. Enter the total days spent in a cooperative care status by a Civilian Health
and Medical Program of the Uniformed Services (CHAMPUS) eligible patient.
EXAMPLE:
63. COOPERATIVE CARE DAYS

302 303 304 305
Ø Ø Ø 2
4-69. CONVALESCENT LEAVE DAYS (FIELD 64, COLUMNS 306 THROUGH 309)
a. Source o f data. This field is automatically computed by AQCESS/CHCS

based on transactions processed in AAD. For nonautomated sites, Item 31, ITRCS.
b. This field is for AD patients only.
c. For nonautomated sites, enter the convalescent leave days actually taken
before the patient was dispositioned from your MTF.
EXAMPLE:
64. CONVALESCENT LEAVE DAYS

306 307 308 309
Ø Ø 2 8
4-70. SUPPLEMENTAL CARE DAYS (FIELD 65, COLUMNS 310 THROUGH 313)
a. This field is automatically computed by AQCESS/CHCS based on

transactions processed in AAD. Patients must be in a status-out to supplemental care
in AAD to accrue days in this category. For nonautomated sites, Item 31, ITRCS.
MD0753 4-66
b. For nonautomated sites, enter the total days spent in supplement care status.
EXAMPLE:
65. SUPPLEMENTAL CARE DAYS

310 311 312 313
Ø Ø Ø 5
4-71. OTHER DAYS (FIELD 66, COLUMNS 314 THROUGH 317)

transactions processed in AAD. For nonautomated sites, an itemized breakdown of
days in this category will be entered in Item 31, ITRCS.
b. For nonautomated sites, enter the total number of days spent in a status-out
in AAD to AWOL (away without leave), to PCS (permanent change of station) home, to
PCS VA, to subsisting out, to TDY, or to other authorized absence (i.e., leave).
EXAMPLE:
66. OTHER DAYS

314 315 316 317
Ø Ø 2 2
4-72. TOTAL SICK DAYS - THIS MTF (FIELD 67, COLUMNS 318 THROUGH 322)

transactions processed in AAD. For nonautomated sites, this is the sum of fields 57 to
66.
b. For nonautomated sites, enter the total sick days the patient spent at your
MTF.
(1) For direct admissions, subtract "Date of This Admission" (field 26) from
"Date of Disposition" (field 23) except for final disposition on the same day as
admission.
MD0753 4-67
(2) For total absent sick cases, subtract "Date of Initial Admission: (field 29)
from "Date of Disposition" (field 23) except for final disposition on the same day as date
of initial admission. Although total absent sick cases will have zero bed days in your
MTF, these patients have been carried administratively on your hospital rolls during this
time.
(3) For cases when initial admission and final disposition occur on the same
day, the MTF making final disposition will enter "ØØØØ1." This is considered 1 sick
day.
(4) For CRO cases and admissions with transfer dispositions on the same
day, enter "ØØØØØ."
c. One method of calculating these days is to convert the dates to Julian

calendar days and subtract as in the following example.
Date of Disposition is 5 May 9X Julian date is 125

Date of This Admission is 15 Apr 9X Julian date is 105
Total Sick Days - This MTF (125 minus 105) 20
d. When a hospitalization begins in one calendar year and ends the following
year, first convert to Julian dates, then subtract the date of this admission from the
number of days in the year (remember, a leap year will have 366 days), then add the
sick days during admission year to the Julian date of disposition.
Number of days in the year 365

Date of This Admission is 23 Dec 93 Julian date is 357
Sick days during admission year (365 minus 357) 08

Date of Disposition is 13 Jan 94 Julian date is 013
Total Sick Days - This MTF (8 plus 13) 21
MD0753 4-68
EXAMPLE:
67. TOTAL SICK DAYS - THIS MTF

318 319 320 321 322
Ø Ø Ø 2 1
4-73. BED DAYS - INTENSIVE CARE UNIT (FIELD 68, COLUMNS 323 THROUGH
326)

based on transactions processed in AAD. For nonautomated sites, AAD office.
b. Bed days spent in ICU are all or part of bed days this MTF but are reported
separately. Accuracy in reporting bed days in the ICU is very important due to the high
cost of operating these units.
c. For nonautomated sites, enter the total number of days that the patient was
assigned to the intensive care unit (ICU) if your MTF is authorized intensive care clinical
services.
EXAMPLE:
68. BED DAYS - ICU

323 324 325 326
Ø Ø Ø 8
MD0753 4-69
Day Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day
1 001 032 060 091 121 152 182 213 244 274 305 335 1
2 002 033 061 092 122 153 183 214 245 275 306 336 2
3 003 034 062 093 123 154 184 215 246 276 307 337 3
4 004 035 063 094 124 155 185 216 247 277 308 338 4
5 005 036 064 095 125 156 186 217 248 278 309 339 5
6 006 037 065 096 126 157 187 218 249 279 310 340 6
7 007 038 066 097 127 158 188 219 250 280 311 341 7
8 008 039 067 098 128 159 189 220 251 281 312 342 8
9 009 040 068 099 129 160 190 221 252 282 313 343 9
10 010 041 069 100 130 161 191 222 253 283 314 344 10
11 011 042 070 101 131 162 192 223 254 284 315 345 11
12 012 043 071 102 132 163 193 224 255 285 316 346 12
13 013 044 072 103 133 164 194 225 256 286 317 347 13
14 014 045 073 104 134 165 195 226 257 287 318 348 14
15 015 046 074 105 135 166 196 227 258 288 319 349 15
16 016 047 075 106 136 167 197 228 259 289 320 350 16
17 017 048 076 107 137 168 198 229 260 290 321 351 17
18 018 049 077 108 138 169 199 230 261 291 322 352 18
19 019 050 078 109 139 170 200 231 262 292 323 353 19
20 020 051 079 110 140 171 201 232 263 293 324 354 20
21 021 052 080 111 141 172 202 233 264 294 325 355 21
22 022 053 081 112 142 173 203 234 265 295 326 356 22
23 023 054 082 113 143 174 204 235 266 296 327 357 23
24 024 055 083 114 144 175 205 236 267 297 328 358 24
25 025 056 084 115 145 176 206 237 268 298 329 359 25
26 026 057 085 116 146 177 207 238 269 299 330 360 26
27 027 058 086 117 147 178 208 239 270 300 331 361 27
28 028 059 087 118 148 179 209 240 271 301 332 362 28
29 029 088 119 149 180 210 241 272 302 333 363 29
30 030 089 120 150 181 211 242 273 303 334 364 30
31 031 090 151 212 243 304 365 31
FOR LEAP YEAR USE REVERSE SIDE
Figure 4-3. Julian Date Calendar (Perpetual).
MD0753 4-70
4-74. BED DAYS - ADMITTING CLINIC SERVICE (FIELD 69, COLUMNS 327
THROUGH 330)
a. Source of data. This field is system-generated by AQCESS/CHCS based on

transactions processed in AAD. For nonautomated sites, AAD office.
b. For nonautomated sites, enter the total number of days that the patient is
assigned to the admitting clinic service during the entire period of hospitalization. For
example, if a patient is admitted to General Surgery for 3 days, is moved to Cardiology
for 2 days, returns to General Surgery for 6 days, is subsequently moved to Internal
Medicine for 2 days, and returns to General Surgery for 12 days before final disposition,
the total bed days accrued in the admitting clinic service (General Surgery) is 21.
EXAMPLE:
69. BED DAYS - ADMITTING

327 328 329 33Ø CLINIC SERVICE
Ø Ø 2 1
4-75. CLINIC SERVICE - SECOND (FIELD 70, COLUMNS 331 THROUGH 334)

b. For nonautomated sites, enter the MEPRS clinic code (see table 4-18) for the
second clinic service to which the patient was assigned during this period of
hospitalization. In the following example, Cardiology is the second clinic service to
which the patient is assigned.
EXAMPLE:
70. CLINIC SERVICE (SECOND)

331 332 333 334
A A B A
MD0753 4-71
4-76. BED DAYS SECOND CLINIC SERVICE (FIELD 71, COLUMNS 335 THROUGH
338)

b. For nonautomated sites, enter the total number of days that the patient was
assigned to the second separate/different MEPRS clinical service. In the following
example, the patient was assigned to the second clinic service (Cardiology) for 2 days.
EXAMPLE:
71. BED DAYS SECOND CLINIC SERVICE

335 336 337 338
Ø Ø Ø 2
4-77. CLINIC SERVICE THIRD (FIELD 72, COLUMNS 339 THROUGH 342)

b. For nonautomated sites, enter the MEPRS clinic code (see table 4-18) for the
third separate/different clinical service to which the patient was assigned during this
period of hospitalization. In the following example, Internal Medicine is the third clinical
service to which the patient is assigned.
EXAMPLE:
70. CLINIC SERVICE (THIRD)

339 340 341 342
A A A A
4-78. BED DAYS THIRD CLINIC SERVICE (FIELD 73, COLUMNS 343 THROUGH
346)

MD0753 4-72
b. For nonautomated sites, enter the total number of days that the patient was
assigned to the third separate/different MEPRS clinic service. In the following example,
the patient was assigned to the third clinic service (Internal Medicine) for 2 bed days.
EXAMPLE:
73. BED DAYS THIRD CLINIC SERVICE

343 344 345 346
Ø Ø Ø 2
4-79. CLINIC SERVICE DISPOSITION (FIELD 74, COLUMNS 347 THROUGH 350)
a. Source of data . This field is system-generated by AQCESS/CHCS based on

b. For nonautomated sites, enter the MEPRS clinical service code (see table 4-
18) for the service from which the patient was dispositioned. Report CRO cases as
MEPRS code XXXA and total absent sick cases as YYYA.
c. With few exceptions, the clinic service from which the patient is dispositioned
will be the admitting (field 24), the second (field 70), or third (field 72) clinic service to
which the patient was assigned. In the following example, the patient is dispositioned
from General Surgery, the admitting clinic service.
EXAMPLE:
70. CLINIC SERVICE DISPOSITION

347 348 349 350
A B A A
4-80. BED DAYS DISPOSITION CLINIC SERVICE (FIELD 75, COLUMNS 351
THROUGH 354)

MD0753 4-73
b. For nonautomated sites, enter the total number of days that the patient spent
in the dispositioning clinic service for the entire period of this hospitalization.
c. In the following example, the patient accrued 21 total bed days in the
dispositioning clinic service.
EXAMPLE:
75. BED DAYS DISPOSITION

351 352 353 354 CLINIC SERVICE
Ø Ø 2 1
4-81. CONVALESCENT LEAVE RECOMMENDED (FIELD 76, COLUMNS 355

THROUGH 357)
a. Source of data. Discharge summary, narrative summary or nurse's notes.
b. These are convalescent leave days recommended by the discharging

physician to an AD service member's unit commander.
c. This field will be completed by clinical records personnel. In the following

example, 10 days of convalescent leave was recommended by the physician.
EXAMPLE:
76. CONVALESCENT LEAVE RECOM-

355 356 357 MENDED
Ø 1 Ø
4-82. PATIENT ACUITY DAYS (FIELDS 77 TO 82, COLUMNS 358 THROUGH 381)
These fields are reserved for future use. Upon implementation of a patient acuity
system, the user's manual will be updated. Leave these fields blank.
MD0753 4-74
4-83. DO NOT USE THIS SPACE (FIELD 83, COLUMNS 382 THROUGH 387)
a. The AQCESS/CHCS systems will place an "F" in the first position of this field
for those records forced through edits in the clinical records module.
b. For nonautomated sites, leave this field blank.
4-84. TYPE RECORD (FIELD 84, COLUMNS 388 THROUGH 393)
a. This field is system-generated or updated at transmittal time by

AQCESS/CHCS. For nonautomated sites, the following codes will be used to identify
the disposition status of records.
b. The first column indicates the disposition of the record.
(1) Code "D" is for records of dispositioned patients where the clinical
records supervisor has approved the record for transmittal to PASBA. Currently, only D
records will be sent by TOE hospitals and other nonautomated sites.
(2) Code "E" is for incomplete records of dispositioned patients.
(3) Code "F" is for records of patients currently on hospital rolls the date of
the monthly IPDS records transmittal.
(4) Code "C" is for record cancellation. The C record will be produced if a D,
E, or F record was previously transmitted to PASBA and then had to be cancelled.
Cancelled records will not be used for reporting purposes by PASBA.
(5) A record coded D or E in the first column of the type record field will
replace any record at PASBA coded F, if the MTF code and the patient register number
are the same as on the record being replaced. A record coded D will replace a record
coded E if the MTF code and the patient register number are the same as on the record
being replaced.
c. The second column of the type record field indicates the number of times the
record has been transmitted (change version). Acceptable codes are Ø-9. If more than
nine changes to a record are transmitted, use A-M. Change version numbers will begin
with zero each time a different record disposition status is reported (i.e., D, E, F, C).
d. The third throug h sixth columns of this field indicate the year and month of
transmittal. The format is YYMM. The date indicator must be updated with each
subsequent transmittal of any record.
MD0753 4-75
e. In the following example, the record of a dispositioned patient, which has
been approved by the clinical records supervisor, was transmitted for the first time in
January 199X.
EXAMPLE:
84. TYPE RECORD

388 389 390 391 392 393
D Ø 9 X Ø 1
Section III. CODING OF THE A&C FORM FROM THE U.S. FIELD MEDICAL CARD
(FMC)
4-85. GENERAL.
DD Form 1380, U.S. Field Medical Card (FMC) (see figure 4-4) is used to record
data similar to that recorded on the ITRCS. The FMC is used by aid stations, clearing
stations, and nonfixed troop or health clinics treating patients while overseas, on
maneuvers, or attached to commands moving between stations. It is also used to
record outpatient visits when the health records are not readily available during a mass
casualty situation. Instructions for the preparation of the FMC are outlined in Chapter 9,
AR 40-66 dated 20 July 1992 and in Subcourse MD0751.
4-86. CODING INSTRUCTIONS
a. Information from the FMC is encoded on DA Form 2985 (A&C Form) only
when the FMC reflects a final disposition or when it represents a CRO. Information on
the FMC of patients transferred to a hospital is incorporated on the A&C Form prepared
at the gaining hospital.
b. Instructions for completing the fields on DA Form 2985 (A&C Form) which
should be coded from the FMC are provided in this lesson. Only those fields on the
A&C Form for which instructions are provided will be coded from the FMC. Instructions
are also provided for field 5 (sex) which is not recorded on the FMC but which will be
coded on the A&C Form. Unused fields will be left blank.
4-87. MTF CODE (FIELD 1, COLUMNS 2 THROUGH 5)
NOTE: In the following instructions, items cited as "Source of Data" correspond to the
numbered items on the FMC.
MD0753 4-76
a. Source of data. The AAD office. See also paragraph 4-7 of this lesson.
b. Enter the code for the gaining MTF from table 4-1. Codes listed in table 4-1,
as well as TOE Hospital codes, may be found in the Individual Patient Data System
(IPDS) User's Manual.
4-88. REGISTER NUMBER (FIELD 3, COLUMNS 9 THROUGH 15)
a. Source of data. The AAD office. See also paragraph 4-9 of this lesson.
b. Enter the next available register number from the register number log book for
each admission. Register numbers begin with number one for the first patient admitted
to the reporting MTF and continues consecutively until close of the facility.
MD0753 4-77
Figure 4-4. DD Form 1380 (U.S. Field Medical Card).
MD0753 4-78
4-89. PAY GRADE (FIELD 4, COLUMNS 16 THROUGH 17)
a. Source of data. Item 3, FMC. See also paragraph 4-11.
b. Enter the appropriate data code from table 4-3. Record the patient's pay
grade as of the date the casualty occurred.
4-90. SEX (FIELD 5, COLUMN 18)
a. Source of data. Remarks section of the FMC. See also paragraph 4-12.
b. Enter the appropriate code (M for male, F for female) from table 4-4.
4-91. AGE AT ADMISSION (FIELD 7, COLUMNS 27 THROUGH 29)
b. Enter the appropriate data code from table 4-5.
4-92. RACE (FIELD 8, COLUMN 30)
a. Source of data. Item 10, FMC. See paragraph 4-15.
4-93. LENGTH OF SERVICE (FIELD 10, COLUMNS 32 THROUGH 34)
4-94. SOCIAL SECURITY NUMBER (SSN) (FIELD 12, COLUMNS 37 THROUGH 45)
b. Enter the complete SSN for U.S. active duty uniformed services personnel.
MD0753 4-79
4-95. BENEFICIARY CATEGORY (FIELD 15, COLUMNS 50 THROUGH 52)
a. Source of data. Item 5, FMC and AAD office.
4-96. UNIT LOCATION (STATE OR COUNTRY CODE) (FIELD 17, COLUMNS 62

THROUGH 63)
a. Source of data. The AAD office. See also paragraph 4-29.
b. Enter the state code from table 4-2 or country location code from the list in the
Individual Patient Data System (IPDS) User's Manual. For units operating outside of
their home station, this is the deployed location of operation.
4-97. TRAUMA (FIELD 19, COLUMN 71)
a. Source of data. Items 16 and 19, FMC. See also paragraph 4-31.
b. Enter the appropriate data code from table 4-14. A cause of injury code must
also be entered in field 35.
4-98. SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION (FIELD 20,

COLUMN 72)
a. Source of data. The source of admission will be direct to military hospital from
other than the emergency room for all cases except CRO. The authority for admission
is not applicable. See also paragraph 4-22.
b. Enter the code "1" for all cases except CRO. Enter "C" for CRO cases.
4-99. TYPE OF DISPOSITION (FIELD 21, COLUMNS 73 THROUGH 74)
b. Enter appropriate code from table 4-15.
4-100. DATE OF DISPOSITION (FIELD 23, COLUMNS 81 THROUGH 86)
b. Enter the date of disposition using the format YYMMDD, where Y = year,
M = month, and D = day.
MD0753 4-80
4-101. DATE OF THIS ADMISSION (FIELD 26, COLUMNS 97 THROUGH 102)
b. Enter the date of this admission using the format YYMMDD, where Y = year,
M = month, and D = day.
4-102. TOTAL SICK DAYS THIS MTF (FIELD 67, COLUMNS 318 THROUGH 322)
b. Enter the number of days between the date the patient was admitted and the
date of disposition. Enter "ØØØØØ" for CRO cases or for a patient who died or was
transferred on the day of admission. Zero fill to the left.
4-103. CAUSE OF INJURY (FIELD 35, COLUMNS 134 THROUGH 136)
b. Enter the appropriate external cause of injury code from appendix B for
patients suffering battle injuries or wounds, nonbattle accidents, violence, or poisonings
(patients coded Ø through 9 in field 19).
4-104. UNDERLYING CAUSE OF DEATH (FIELD 32, COLUMN 121)
b. Enter the appropriate data code from table 4-19 to indicate which of the eight
diagnostic fields identifies the cause of death.
4-105. DIAGNOSIS CODING (FIELDS 36 to 43, COLUMNS 137 THROUGH 200)
a. Source of data. Item 14, FMC.
b. Use the ICD-9-CM to code the diagnostic condition(s) for which the patient
was treated.
c. Use the first three/four/five columns of the diagnosis fields for the ICD-9-CM
codes. Do not zero fill the fourth column for three-digit ICD-9-CM codes. Leave the fifth
column blank for four-digit ICD-9-CM codes.
d. Leave the sixth column blank.
MD0753 4-81
e. The seventh column is reserved for DOD diagnostic code extenders which are
listed in Appendix A, Triservice Disease and Procedure Coding Guidelines, dated 1
January 1991.
f. Enter a code from table 4-21 in the eighth column to indicate where the
diagnostic condition was treated or managed.
4-106. PROCEDURES CODING (FIELDS 44 TO 51, COLUMNS 201 THROUGH 264)
b. Enter the three or four-digit code from ICD-9-CM, volume 3, in the first three
or four columns of the procedures fields to indicate any surgical or other procedures that
were performed on the patient.
c. Do not zero fill to the fourth position for three-digit codes.
d. Leave the fifth column blank.
e. Enter a code from table 4-22 in the sixth column to indicate the place where
the procedure was performed.
f. Enter code Ø1-99 in the seventh and eighth columns to indicate the number of
times a procedure was performed at the reporting MTF.
4-107. DISPOSITION OF THE FIELD MEDICAL CARD (FMC)
a. If DD Form 1380, the Field Medical Card (FMC) is generated in a combat

zone but the patient is not admitted to a hospital, the FMC will be sent to the medical
command and control headquarters or the command surgeon for statistical coding.
After coding, the FMC will be disposed of in accordance with (IAW) AR 40-66 and
AR 25-400-2.
b. When the patient is transferred to a hospital, the FMC will be used to prepare
the inpatient treatment record (ITR). The FMC will then become part of the ITR.
c. When the FMC is used to record outpatient treatment in peacetime operations

or during training exercises, the original DD Form 1380 will be forwarded to the
custodian of the patient's Health Record or Outpatient Treatment Record for inclusion in
that record.
d. All carbon copies of DD Form 1380 will be disposed of IAW AR 25-400-2.
MD0753 4-82
Section IV. TRANSMITTAL PROCEDURES AND DATA ACCESS
4-108. GENERAL
a. The Automated Quality of Care Evaluation Support System (AQCESS) or

Composite Health Care System (CHCS) Individual Patient Data System (IPDS) record
transmittals will be submitted twice each month. Records must be submitted on the
scheduled transmittal dates and should not be delayed to await late records. Late
records should be submitted in the next scheduled transmittal.
(1) Each month on or about the 4th working day, create a monthly transmittal
tape.
(2) Create an interim transmittal tape on or about the 15th working day of
each month.
b. Complete the IPDS records listed as missing on the monthly IPDS Records
Report (RUC 299, Part C), and include these records in the next scheduled transmittal.
c. Forward the magnetic tape/cassette by First-Class Mail or Priority Mail to

Commander, U.S. Army Medical Department Center and School, Directorate of Patient
Administration Systems and Biostatistics Activities, (HSHI-QPS), Fort Sam Houston, TX
78234-6100.
d. Label each transmittal tape/cassette on the outside as follows:
REPORTING MTF CODE:

DATE CREATED:
TYPE OF TRANSMITTAL: (End of Month or Interim)
TOTAL RECORD COUNT:
e. Enclose a copy of the corresponding Records Transmittal Roster to enhance

accountability for every tape/cassette processed.
f. Nonautomated sites requiring data reduction services by the U. S. Army

Patient Administration Systems and Biostatistical Activity (PASBA) must use DA Form
2985, the three-page Admission and Coding Information Form (A&C Form) to record all
patient data for processing into the data base.
(1) Send a fully completed A&C Form plus DA Form 3647, the Inpatient
Treatment Record Cover Sheet (ITRCS) to PASBA.
(2) When it is not feasible to code diagnoses and procedures at that time, the
A&C Form should be completely coded except for the diagnoses and procedures.
MD0753 4-83
g. For assistance, contact the Data Input Section, Patient Administration
Systems Division, DSN 471-5414/6797.
4-109. PASBA2
a. PASBA2 is a program written to provide the medical treatment facilities quick,

easy access to the data it submitted to the Directorate of Patient Administration
Systems and Biostatistics Activities (PASBA), through the Individual Patient Data
System (IPDS). The availability of this data enables clinicians and managers to make
decisions about their patients and their facility in an expeditious manner.
b. PASBA2 User's Manual, dated 21 May 1993, provides instructions and

procedures for operation of the PASBA2 inpatient data retrieval program in all Army
medical treatment facilities.
c. The IPDS records contain information protected under the Privacy Act of
1974. It is essential that you safeguard this data. As a precaution, the chief of Patient
Administration Division (PAD) must install a password program before enabling users
access to PASBA2.
MD0753 4-84
EXERCISES, LESSON 4
INSTRUCTIONS: Complete the following exercises by marking the lettered response

that best answers the question, or by finishing the incomplete statement, or by writing
the answer in the space provided at the end of the question, or by extracting data from
an Inpatient Treatment Record Cover Sheet (ITRCS) and coding the A&C Form
provided.
After you have completed the exercises, turn to "Solutions to Exercises" at the end
of the lesson and check your answers.
1. The purpose of the Individual Patient Data System is to provide:
a. _____________________________
_____________________________
_____________________________.
b. _____________________________.
c. _____________________________
_____________________________.
d. _____________________________
_____________________________
_____________________________.
2. The purposes of DA Form 2985 (Admission and Coding Information) are:
a. _____________________________.
b. _____________________________.
3. Because it is a dual purpose form, DA Form 2985 is known as the

___________ Form.
MD0753 4-85
4. Fields on DA Form 2985 have been arranged so that most of the demographic and
administrative data are on page __________ of the three-page form.
5. Codes on the A&C Form must be written legibly. Alphabetical characters must be
printed as ___________letters. Zero must always be written __________.
6. Nonautomated sites/hospitals should complete applicable fields of the A&C Form in

an original and _________legible copies at the time of admission and maintain these
copies in a suspense file while the patient remains in an inpatient status.
7. At the time of disposition, copies of the patient's A&C Form are removed from the
suspense file and applicable fields on ______ are completed by the Admissions and
Dispositions office.
8. After disposition, the A&C Form is forwarded to the _______

_____________________for filing in the patient's terminal digit file folder to await
completion of the Inpatient Treatment Record (ITR).
9. Upon completion of the Inpatient Treatment Record (ITR), the original and copies of
the A&C Form are removed from the patient's terminal digit file folder and ______ ___
are completed by the Medical Records Administration Branch personnel.
10. In the following example, 1. REPORTING MTF is a ________ on the A&C Form.
1. REPORTING MTF
1 2 3 4 5 6
MD0753 4-86
11. In the following example, blocks 1 through 6 are__________
____________ on the A&C Form.
1 2 3 4 5 6
12. An entry in the following example would be the first
_________ on the patient's Inpatient Treatment Cover Sheet (DA Form 3647).
1. REGISTER NUMBER
13. The MTF code for Brooke AMC, Fort Sam Houston, TX is ___________.
14. The original A&C Form is filed in the patient's ___________

__________.
15. One legible copy of the A&C Form and a copy of the Inpatient Treatment Record
Cover are forwarded to _________________
______________________________for input into the IPDS data base.
16. Information from DD Form 1380, U.S. Field Medical Card (FMC) is encoded on DA
Form 2985 (A&C Form) only when the FMC reflects a__________________________
or when it represents ___________________________________________________.
17. The Automated Quality of Care Evaluation Support System (AQCESS) or the
Composite Health Care System (CHCS) Individual Patient Data System (IPDS) record
transmittals must be submitted ________ each month.
MD0753 4-87
18. A monthly transmittal tape should be created on or about
_______________. An ______________transmittal tape should be created on or about

the 15th working day of each month.
19. Nonautomated sites requiring data reduction services by the U.S. Army Patient
Administration Systems and Biostatistical Activity (PASBA)
should send ______________________________
_____________________to PASBA.
20. The magnetic tape/cassette transmitting IPDS records to PASBA
should be forwarded by _________________or _____

______________ mail.
INSTRUCTIONS: For exercises 21 and 22, the use information which has
been provided or recorded on DA Form 3647 (Inpatient Treatment Record
Cover Sheet) to code data on DA Form 2985 (A&C Form) for the two patients
listed.
In reality, some information on page 1 would be coded during the

admission. THIS IS A TRAINING EXERCISE.
21. Major Joann M. Birchett, a white (not hispanic) patient administration officer, was
born on 1 April 195X. Below is her Inpatient Treatment Record Cover Sheet.
MD0753 4-88
Figure 4-5; DA Form 3647, Inpatient Treatment Record Cover Sheet
MD0753 4-89
Figure 4-6; DA Form 2985 for Exercise 21 (continued).
MD0753 4-90
MD0753 4-91
Figure 4-8; DA Form 2985 for Exercise 21 (concluded).
MD0753 4-92
22. Below is the ITRCS for Master Sergeant Christopher M. Kraft, a black (not
hispanic) patient administration specialist, born on 22 April 196X. Following surgery on
20 Nov 9X, MSG Kraft was assigned to the Orthopedic Clinic Service for 11 days. He
returned to the Rheumatology Clinic Service and remained there until his disposition.
Check your answers
MD0753 4-93
Figure 4-9; DA Form 3647, Inpatient Treatment Record Cover Sheet
MD0753 4-94
Figure 4- 10; DA Form 2985 for Exercise 22 (continued).
MD0753 4-95
MD0753 4-96
MD0753 4-97
1. a. Data for planning, managing, and evaluating the AMEDD medical care
system.
b. Data for medical and epidemiological research.
c. Rapid data retrieval in response to inquiries from HQDA, HSC, OTSG,
DOD, and other authorized organizations and individuals.
d. Management reports and retrieval of special data for the hospital
commander and his staff. (para 4-1b(1) -- (4))
2. a. To be used as a patient admission information document.

b. To be used as a coding transcript. (para 4-4a)
3. A&C or admissions and coding. (para 4-4a(note))
4. One. (para 4-4a)
5. Capital block, Ø. (para 4-5b)
6. Two. (para 4-5a & c)
7. Page 1. (para 4-5d)
8. Medical Records Administration Branch. (para 4-5e)
9. Pages 2 and 3. (para 4-5f)
10. Field. (para 4-3b)
11. Columns. (para 4-3c)
12. Item. (para 4-3d)
13. A14Ø1. (para 4-7b and Table 4-1)
14. ITR (Inpatient Treatment Recort). (para 4-5g)
15. The U.S. Army Medical Department Center and School, Patient Administration
Systems and Biostatistics Activity (PASBA). (para 4-5h)
MD0753 4-98
16. Final disposition, CRO. (para 4-86a)
17. Twice. (para 4-108a)
18. The 4th working day of each month, interim. (para 4-108a(1) -- (2))
19. A fully completed A&C Form plus DA Form 3647 (ITRCS). (para 4-108f(1))
20. First class, priority. (para 4-108c)
21. BIRCHETT, Joann M.
MD0753 4-99
MD0753 4-100
MD0753 4-101
MD0753 4-102
MD0753 4-103
MD0753 4-104
MD0753 4-105
COMMENT SHEET
SUBCOURSE MD0753 Medical Records Administration Branch I EDITION 101

Your comments about this subcourse are valuable and aid the writers in refining the subcourse and making it
more usable. Please enter your comments in the space provided. ENCLOSE THIS FORM (OR A COPY) WITH
YOUR ANSWER SHEET ONLY IF YOU HAVE COMMENTS ABOUT THIS SUBCOURSE..
FOR A WRITTEN REPLY, WRITE A SEPARATE LETTER AND INCLUDE SOCIAL SECURITY NUMBER, RETURN
ADDRESS (and e-mail address, if possible), SUBCOURSE NUMBER AND EDITION, AND
PARAGRAPH/EXERCISE/EXAMINATION ITEM NUMBER.
PLEASE COMPLETE THE FOLLOWING ITEMS:

(Use the reverse side of this sheet, if necessary.)
1. List any terms that were not defined properly.
2. List any errors.
paragraph error correction
3. List any suggestions you have to improve this subcourse.
PRIVACY ACT STATEMENT (AUTHORITY: 10USC3012(B)

4. Student Information (optional)
AND (G))
Name/Rank PURPOSE: To provide Army Correspondence Course Program
SSN students a means to submit inquiries and comments.
Address
USES: To locate and make necessary change to student records.
E-mail Address DISCLOSURE: VOLUNTARY. Failure to submit SSN will prevent

Telephone number (DSN) subcourse authors at service school from accessing
student records and responding to inquiries requiring
MOS/AOC
such follow-ups.
U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL Fort Sam Houston, Texas 78234-6130

US Army Medical Course MD0753-101 Book1 - Medical Records Administration Branch

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ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

Application for enrollment should be made at the Internet website: http://www.atrrs.army.mil.

For comments or questions regarding enrollment, student records, or shipments, contact

NONRESIDENT INSTRUCTION BRANCH

Lesson Paragraphs Page

1 INPATIENT TREATMENT RECORDS........................................ 1-1--1-20 1-1

Section I. Background Information..................................... 1-1--1-4 1-2

Exercises ..................................................................................... 1-37

2 DIAGNOSTIC AND OPERATIVE CODING................................ 2-1--2-19 2-1

Section I. General ................................................................ 2-1--2-6 2-2

Exercises ..................................................................................... 2-22

3 INPATIENT TREATMENT RECORD COVER SHEET............. 3-1--3-6 3-1

Section I. General ................................................................ 3-1--3-3 3-2

Exercises ..................................................................................... 3-17

4 INDIVIDUAL PATIENT DATA SYSTEM...................................... 4-1--4-109 4-1

Section I. General ................................................................ 4-1--4-5 4-2

Exercises ..................................................................................... 4-85

* Appendices under separate cover (Book 2 of 2)

1-1 Completed DA Form 3444-6 used as an Inpatient Treatment Record.............. 1-3

2-1 Volume 1, Table of Contents (Continued)............................................................. 2-4

4-1 DA Form 2985 (Admission and Coding Information) .......................................... 4-5

1-1 Filing sequence for documents in ITR folder............................................................1-31

3-1 Abbreviations used on the ITRCS.............................................................................3-4

4-1 Medical treatment facility (MTF) codes .................................................................. 4-10

MEDICAL RECORDS ADMINISTRATION BRANCH I

Lesson 1, Inpatient Treatment Records.

Lesson 2, Diagnostic and Operative Coding.

Lesson 3, Inpatient Treatment Record Cover Sheet.

Lesson 4, Individual Patient Data System.

Lesson Materials Furnished:

Procedures for Subcourse Completion:

We suggest that you follow these study procedures:

--Read and study each lesson assignment carefully.

Student Comment Sheet:

LESSON 1 Inpatient Treatment Records.

LESSON ASSIGNMENT Paragraphs 1-1 through 1-20.

1-1. Identify the functions of the Inpatient Treatment

1-2. List the essential elements of the Inpatient

1-3. Identify the correct sequence of forms filed in the

1-4. Identify the variations of the Inpatient treatment

1-5. Identify the disposition of Inpatient Treatment

SUGGESTION After reading and studying the assignment, complete

INPATIENT TREATMENT RECORDS

Section I. BACKGROUND INFORMATION

a. Medical Record. As explained in Subcourse MD0750, Introduction to Medical

c. Purpose. The purpose of an ITR is to:

(1) Provide a complete medical history on the management (including

(3) Provide medico-legal support for the care provided.

(4) Provide information (as needed) for education and research.

a. MTF Commander. The commander of the medical treatment facility (MTF) is

1-4. FOR WHOM PREPARED

a. An Inpatient Treatment Record is prepared for:

b. An Inpatient Treatment Record is not prepared for:

(1) Stillbirths (delivery of a dead infant).

Section II. VARIATIONS OF INPATIENT TREATMENT RECORDS

1-5. TYPES OF INPATIENT TREATMENT RECORDS

1-6. ROUTINE INPATIENT RECORD

a. A routine Inpatient Treatment Record is required for patients receiving long-term

1-7. ABBREVIATED MEDICAL RECORD

1-8. CARDED FOR RECORD ONLY (CRO)

b. Medical board examinations performed in an outpatient facility.

b. DA Form 3647, Inpatient Treatment Record Cover Sheet (ITRCS), is initiated in