SF602
Medical Record - Serology Record
Standard Form 602 (SF 602), Medical Record - Serology Record, is a two-sided medical record, Rev. 8/1998. Its footer reads Prescribed by GSA/ICMR and cites FPMR (41 CFR) 101-11.203(b)(10, cut off at the edge of the PDF. GSA hosts a copy in its forms library.
The form has seven sections: the history of the present infection, past sexually transmitted infections or treatments, treatment, a laboratory summary, evaluation of therapy, a block for the medical officer closing the record and a block for the medical officer sending an abstract to the Department of Veterans Affairs on discharge. A physician signs Section I and each treatment line, and the patient signs a statement that the diagnosis and the nature of the disease have been explained.
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Source of referral, what it was incident to, dates of onset, requested treatment and diagnosis, diagnostic criteria, diagnosis, clinical data, STD contact form serial numbers, and the recommended treatment and follow-up.
Three rows with date, disease (give stage), whether it was prior to federal service, treatment (type, amount and dates), treating agency and place.
Three numbered lines with the treatment, date started, date ended and signature of physician.
Darkfield examination, nonspecific treponemal tests (VDRL, RPR, ART), specific treponemal tests (FTA - ABS, MHA-TP, TPHA, TPI) and spinal fluid examinations.
Date, facility, satisfactory or unsatisfactory result, date of retreatment and physician's signature, then incomplete follow-up, home address on separation, type of separation, case resume and reinfection.
Name (typed or printed), signature, station and date for the officer closing the record and for the officer sending the abstract to the Department of Veterans Affairs.
For typed or written entries, give the name (last, first, middle), ID No or SSN, sex, date of birth and rank or grade, plus the sponsor, facility, register and ward blocks.
The physician fills in the history, diagnosis and recommendations, then signs. The patient signs and dates the statement below it.
List past infections or treatments in Section II and each treatment in Section III, with dates and the physician's signature.
Fill in Section IV for each test. The treponemal test rows ask for the result to include the titer value.
A footnote says a satisfactory result cannot be reported without normal spinal fluid findings, and another says to specify the type of an unsatisfactory result.
The medical officer closing the record completes Section VI, and Section VII is used when an abstract goes to the Department of Veterans Affairs on discharge.
The form prints no instructions beyond its blocks and footnotes. These steps follow them.
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The PDF gives no filing address. It has a Records Maintained At block, a block for the civilian health department to which a case resume was sent, and Section VII for an abstract sent to the Department of Veterans Affairs on discharge.
The statement the patient signs in Section I ends: Disclosure of this information is required by law.
The footnote lists Infectious Relapse: Sero-Relapse, Neuro-Relapse, Incomplete data on Spinal Fluid, Other (Specify).
The footer reads STANDARD FORM 602 (REV. 8-98), Prescribed by GSA/ICMR, with the FPMR citation cut off at the edge. GSA's page lists the current revision date as 08/1998.
SF600
127 fields, 2 pages
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186 fields, 2 pages
SF515
29 fields, 1 page
SF513
34 fields, 1 page
SF509
92 fields, 2 pages
SF88
199 fields, 2 pages
The form does not say in words who fills it out. Its signature lines and blocks name these people.
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The footer reads Prescribed by GSA/ICMR and cites FPMR (41 CFR) 101-11.203(b)(10, cut off at the edge of the PDF. GSA hosts a copy in its forms library.
A statement in Section I that the medical officer has informed them of the diagnosis, that the nature of the disease has been explained, and that their cooperation is necessary in the treatment and prolonged observation. It ends: Disclosure of this information is required by law.
Darkfield examination, nonspecific treponemal tests (VDRL, RPR, ART), specific treponemal tests (FTA - ABS, MHA-TP, TPHA, TPI) and spinal fluid examinations.
A footnote in Section V says a satisfactory result cannot be reported without normal spinal fluid findings.
Section VI is for the medical officer closing the record. Section VII is for the medical officer sending an abstract to the Department of Veterans Affairs on discharge.
