Enclosure (1) to COMDTINST 6010.18A
A diagnosis must be included on each duty status Status chit issued,
including FFDs chits. If the Profile practitioner does not want the diagnosis
to appear on the binnac list, enter an asterisk (*) after the
written diagnosis. Thus a data base entry of "gonorrhea*" will appear as " "
on the binnacle
list. If inpatient, place a "$" after the diagnosis. If the illness or injury
resulting in the duty
restriction was (S) ports, (O) ccupational, (M) otor vehicle, or (A) lcohol
related, check the applicable | S | O | M | A | block(s). More than one block
can be checked if appropriate.
Note: Recording an alcohol related injury may not require an "official "
determination of an alcohol related incident. Refer to Chapter 20,
COMDTINST M1000.6 (series), Personnel Manual, for further guidance.
CLAMS will accommodate two concurrent duty statuses on a patient. For
example, a shorter duration NFFD for a viral syndrome can be superimposed
on a long-standing FFLD status for an ankle sprain. CLAMS will also
accommodate two serial (one after the other) statuses. For example, one day
of NFFD followed by a week of FFLD for an ankle sprain. These can be
noted on the same duty status chit and entered into the database at the same
time. Both diagnoses and/or statuses will appear on the binnacle list.
Note: Your binnacle list(s) can be generated from information in this
section of the Status-Profile
form.
Lower half of the form - is for specific workload Profile infor
mation. If the visit will count as an outpatient visit (OPV) as defined by
COMDTINST M000.1
Chapter 6-A-1, the care giver's initials are required. For medical and dental
record purposes, the OPV care giver is the individual who ultimately
assumes responsibility for the patient's treatment. You are the care giver for
a visit if:
a) your SOAP note is recorded in the health record,
b) you assumed ultimate responsibility for the patient's treatment, and
c) you signed the medical record entry.
Answering a question about a finding or treatment for another practitioner
does not make you the caregiver of record. Also, a health services
technician who performs a preliminary assessment (history, exam, and a
plan) and then turns the patient over to a medical officer or other practitioner
is not the OPV care giver and should not initial a box. A telephone call by a
health services technician to the duty practitioner in regard to a patient may
constitute a transfer of responsibility, provided the duty practitioner's
assessment and plan are recorded in the health record for his signature.
4
Previous Page
