Page 420 - 2021 IDMT Digital

AFI 44-102, Patient Care and Management of Clinical Services 5HTXLUHV UHSRUWLQJ RI
KRPLFLGHV VXLFLGHV DWWHPSWHG VXLFLGH UREEHU\ DJJUDYDWHG DVVDXOW RWKHU VH[ RIIHQVHV QRW
VH[XDO DVVDXOW LQWHQWLRQDO GUXJ RYHUGRVH DQG QDUFRWLF GUXJ RYHUGRVH WR WKH DSSURSULDWH ODZ
HQIRUFHPHQW DQG RU FRPPDQG DXWKRULWLHV
DoDI 6495.02, The Sexual Assault Prevention and Response (SAPR) Program +HDOWKFDUH
SURYLGHUV ZLOO UHSRUW VH[XDO DVVDXOWV RI DOO DFWLYH GXW\ DQG PLOLWDU\ GHSHQGHQWV \HDUV RI DJH
DQG ROGHU WR WKH VH[XDO DVVDXOW UHVSRQVH FRRUGLQDWRU
DoDD 6400.1, Family Advocacy Program (FAP) +HDOWKFDUH SURYLGHUV ZLOO UHSRUW FKLOG
QHJOHFW DEXVH VSRXVH DEXVH DQG VH[XDO DVVDXOW YLFWLPV ZKR DUH XQGHU WKH DJH RI WR WKH
)$3
DoDI 6490.11, DoD Policy Guidance for Management of Mild Traumatic Brain
Injury/Concussion in the Deployed Setting (Follow guidance from this publication as well as
FRPEDWDQW FRPPDQG &2&20 JXLGDQFH IRU WKH PDQDJHPHQW RI PLOG 7%, LQ D GHSOR\HG
HQYLURQPHQW

FORMS
AF IMT 4336, IDMT Patient Encounter Form 'RFXPHQW DOO SDWLHQW HQFRXQWHUV
AF IMT 623a, On-The-Job Training Record Continuation Sheet 8VHG WR GRFXPHQW
FRPSHWHQF\ YHULILFDWLRQ
AF IMT 1098, Special Task Certification and Recurring Training 8VHG WR GRFXPHQW 473V
DQG IXQFWLRQDO DUHD WUDLQLQJ %LR 3XEOLF +HDOWK 'HQWDO HWF
AF Form 579, Controlled Substance Register &RQWUROOHG LWHPV DUH DFFRXQWHG IRU DQG
LQYHQWRULHG XWLOL]LQJ WKLV IRUP
AF Form 348, Line of Duty Determination ,QIRUPDO DQG )RUPDO /LQH RI 'XW\ 'HWHUPLQDWLRQV
AF Form 614 or 614A, Charge Out Record 8VHG LQ SODFH RI D UHFRUG RU IROGHU UHPRYHG IURP
SK\VLFDO ILOHV WR VKRZ WKDW WKH UHFRUG LV FKDUJHG RXW

2l00A, Health Record-Outpatient +DUG FRS\ QRQ HOHFWURQLF PLOLWDU\ PHGLFDO UHFRUG
2l00B, Health Record-Dental +DUG FRS\ QRQ HOHFWURQLF PLOLWDU\ GHQWDO UHFRUG
SF 600, Chronological Record of Medical Care 8VHG WR UHFRUG DOO PHGLFDO WUHDWPHQW
SF 603, Health Record-Dental DQG SF 603a, Health Record-Dental Continuation 8VHG WR
UHFRUG DOO GHQWDO WUHDWPHQW
DD Form 2766, Adult Preventive and Chronic Care Flowsheet ,V WKH PLQLPXP GHSOR\HG
PHGLFDO GRFXPHQWDWLRQ UHTXLUHG
AF Form 422, Notice of Air Force Members Qualification Status (&ODVVLILHV LQGLYLGXDOV
DFFRUGLQJ WR SK\VLFDO IXQFWLRQDO DELOLWLHV DQG ORQJ WHUP DYDLODELOLW\ IRU ZRUOGZLGH GXW\

[ 419 ]