Arrival and contact
Log number, treatment facility, records maintained at, home address or duty station, sex, age, duty or local and home phones, and arrival date, time and transportation.
SF558
Medical Record - Emergency Care and Treatment
- Agency
- GSA
- Revision
- Rev. 9/1996
- Fillable fields
- 199
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
Standard Form 558 (SF 558): Emergency Care and Treatment
Standard Form 558 (SF 558), Emergency Care and Treatment, is a two-page medical record printed as STANDARD FORM 558 (REV. 9-96). Its footer says Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10), and GSA hosts a copy in its forms library, where it is listed as Medical Record - Emergency Care and Treatment.
The first page, labeled (Patient), covers arrival, contact details, military status, insurance, the chief complaint, the category of treatment, vital signs, lab and X-ray orders, disposition and discharge instructions, with a line for the patient's signature. The second page, labeled (Doctor), holds test results, the provider history and physical, consults, the diagnosis and codes, and the provider's signature and stamp.
You can fill it out free in your browser on this page and download the result without an account.
What's on SF 558
Status, insurance and history
Military status (PRP, flying status), third party insurance, DD 2568 in chart, insurance company, medical history obtained from, current medications, allergies, injury or occupational illness, emergency room visit and tetanus.
Complaint, triage and vitals
CHIEF COMPLAINT, CATEGORY OF TREATMENT (emergent, urgent or non-urgent) with a time and initials, and vital signs: BP, pulse, resp, temp and wt.
Lab, X-ray and other orders
Check boxes for lab orders such as CBC/DIFF, PT/PTT and UA, X-ray orders such as C-SPINE and HEAD CT, orders for pulse ox, monitor and ECG, and a timed orders log.
Disposition and release
Disposition (home, full duty, modified duty, quarters or off duty), condition upon release, admit or referral details, time of release, discharge instructions and the patient's signature.
Doctor page
TIME SEEN BY PROVIDER, TEST RESULTS (CBC, ABG/pulse ox, radiology, EKG interpretation and others), PROVIDER HISTORY/PHYSICAL, CONSULT WITH, DIAGNOSIS and CODES.
Page 1 is the patient record and page 2 is the doctor record. Each has its own patient identification block.
How to fill out SF 558
- 1
Identify the patient
Each page has a PATIENT'S IDENTIFICATION block. For typed or written entries, it asks for the name (last, first, middle), ID no. (SSN or other) and the hospital or medical facility.
- 2
Record arrival and history
Enter the arrival date (Day, Month, Year), time and transportation, the address and phones, insurance, current medications, allergies and any injury details.
- 3
Note the complaint and triage
Write the chief complaint, check emergent, urgent or non-urgent with a time and initials, and record vital signs with their times.
- 4
Mark orders and responses
Check the lab, X-ray and other orders, then log each order with its time, who ordered and completed it, and the patient's response.
- 5
Complete the doctor page
Enter the time seen by provider, test results, the history and physical, any consult, the diagnosis and codes, then the provider signs and stamps it.
- 6
Record disposition and release
Mark the disposition, condition upon release and time of release, write the discharge instructions, and the patient signs that they received and understand them.
The form prints no step-by-step instructions. These steps follow its blocks.
Why fill Form SF558 on indox
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- Works on a phone, tablet or computer
Where it goes and what the form says
Where it goes
The PDF prints no filing address. It is labeled Medical Record, and the RECORDS MAINTAINED AT box names where the records are kept.
Two pages, two labels
Page 1 is labeled EMERGENCY CARE AND TREATMENT (Patient) and page 2 EMERGENCY CARE AND TREATMENT (Doctor). Each has its own patient identification block.
Prescribing note
The footer says Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10). The form also prints NSN 7540-01-075-3786.
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Who completes SF 558?
The form prints signature lines for the provider, a resident or medical student and the patient. It does not say who fills in each block.
Official sources and the blank
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Questions about Form SF558
Who issues SF 558?
The footer says Prescribed by GSA/ICMR FPMR (41 CFR) 101-11.203(b)(10). GSA hosts a copy in its forms library, printed as STANDARD FORM 558 (REV. 9-96).
Why does SF 558 have two pages?
Page 1 is labeled (Patient) and covers arrival through discharge. Page 2 is labeled (Doctor) and holds test results, the history and physical, the diagnosis and the provider's signature.
Who signs SF 558?
The provider signs and stamps page 2, with a separate line for a resident or medical student. The patient signs page 1 under the statement I have received and understand these instructions.
What are the categories of treatment on SF 558?
The form has three boxes, EMERGENT, URGENT and NON-URGENT, with a time and initials. It prints no definitions for them.
What patient details does SF 558 ask for?
For typed or written entries, the name (last, first, middle), ID no. (SSN or other) and hospital or medical facility, plus the home address or duty station, sex, age and phone numbers.