Enclosure (1) to COMDTINST 6010.18A
Top right date - The date must be filled in at each visit.
Top right - If mechanical imprinting was not used or if the
addressograph card lacks some information, this section should be
filled in at each visit. Otherwise, leave it blank.
Bottom - The "Third Party" block is to be filled out by the clinic staff.
Note that it includes dependent/retiree referral for inpatient care at a
Reverse - (not shown here) Blank except for privacy act information
and audit codes. This is a good place to put any addresses to which
requests for old medical records should be sent.
REVIEW PROCESS FOR REFERRALS, PAP SMEARS, BIOPSIES, AND MAMMOGRAMS
When referrals, Pap smear results, biopsy results, or mammographic studies are returned to the
facility, they are to be stapled to a blank Visit Profile and then given to the referring ractitioner for
The practitioner shall initial the OPV Caregiver box and draw a line through either "Pap",
"Biopsy", or the referral type (e.g., Dental, ENT, Surgery) on the form as appropriate to indicate the
report was received and reviewed. When entered into the database, the item will be deleted from
that practitioner's listing of outstanding referrals/Paps/biopsies/mammograms.
Referral review process exceptions - Alcohol, emergency, and general practice referrals are not
included on outstanding referral reports, so the return visit 'cross-out' step is not equired. Such
referrals will be counted in the monthly totals.