Completing The Adult Preventive and Chronic Care Flow Sheet DD Form 2766 Rev Apr 07

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DD Form 2766 A Tri-service form Use for ADULTS Obtained through Navy Supply system http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm DD 2766 NSN 0102-LF-984-8400 DD 2766C (cont. sheet) NSN 0102-LF-984-9600

DD Form 2766 SECNAV 6120 (under revision) Periodic Health Assessment Requires documentation on DD2766 BUMED NOTICE 6150 – Guidance on completing DD 2766 supercedes Chapter 16, Manual of Medical Department (under revision to reflect change) Documentation face-to-face encounter not solely a record review all levels of providers use it not only privileged providers

Every patient should have pages 1 and 2 updated at every visit. 3. Medications - list current Rx’s & OTC medications NKDA Atenolol 50 mg qd Premarin 0.625 mg qd Provera 2.5 mg qd Flonase 1 squirt ea nostril qd HTN—Dx’d 1995 Hypothyroidism—Hashimoto’s Allergic rhinitis This is the top of page 1 of DD Form 2766. Every patient should have pages 1 and 2 updated at every visit. 1. Allergies Document medication and environmental allergies. Only section 3 may be completed in pencil: s/p appendectomy 1982 s/p R breast biopsy 1995--benign The remainder of page 1 must be completed in pen.

This is the bottom of page 1-- where counseling is documented. 1/10/00 57 F, N, I 3/17/00 57 A—2/wk To—none 6/20/00 57 AD This is the bottom of page 1-- where counseling is documented. To document counseling, simply enter the date, the patient’s age, and the codes for the topics that were discussed. On St. Patrick’s Day, they discussed alcohol and tobacco use. The provider really only needs to enter the codes (A and To). However, he or she can enter more detail if desired (again, for easy reference in the future). On 20 Jun 00, advance directives were discussed. If there is no prewritten code for the counseling topic, one can be created. If new codes need to be created, it’s best if they are agreed upon by the clinic. At WHMC, the Internal Medicine clinic has designated AD as the code for advance directive counseling. On 10 Jan 00, this 57 y.o. woman and her provider discussed osteoporosis and fracture prevention. They discussed the importance of weight-bearing exercise (F), calcium and vitamin D intake (N), and fall prevention (I). AD Advance Directive First, always ensure that the patient’s identifying information is entered. If you’re using a created code, ensure that it is included on the list of codes and topics. 20 June 2000 When an advance directive is filed in the chart (in Section IV), enter the date here. Jones Mary 30/123-45-6789

After you’ve entered a test result, When entering the family history, use the relationship abbreviations that are defined on the form (M, F, S, etc.). After you’ve entered a test result, determine when that test should be performed again, then fill in the corresponding circle. This will serve as a reminder at future visits. The bottom of page 2 is the Screening Exam section. Once you enter a calendar year and age, go ahead and enter them across the whole row. M—breast ca Dx’d at 48; F—colon ca Dx’d at 68 M—HTN, MI at 53 MGM—type 2 diabetes S—major depression For any other test, you may enter a code for the result... When any test is performed, enter the result in the appropriate cell. The actual result must be entered for: weight height BP cholesterol 2006 57 2007 58 2008 59 2009 60 2010 61 2011 62 This is the top of page 2 of DD Form 2766. Enter any family history that is pertinent. For example, since the age when her mother had her myocardial infarction (MI) is important, enter the age. 132 / 86 Chol 122 TG 21 HDL 65 LDL 53 142 66” ...and the codes can be found here! BP should be checked next year. But lipids don’t need to be checked for another 5 years.

And note that she should be offered it again next year. Notice that, if a test was ordered and the results are pending, the entry should be in pencil. The final result should be entered—in pen—once it is available. Only “X” needed to be entered for the Pap result. This provider opted to enter more information. N 3/15/07 pending 3/15/07 X--ASCUS repeat 3 mo Note that “R” is a valid entry. This patient was offered flexible sigmoidoscopy but refused it. N R This is the bottom of page 2—a continuation of the Screening Exam section.

Section 8. Occupational History: Document monitoring programs, e.g. hearing conservation, radiological, lead, asbestos; Occupational screening exams are highly dependent upon the patient’s occupation and exposure history. If indicated, use blocks 7((20), (21), and (22)) to document occupational monitoring programs, e.g., hearing conservation, radiation, asbestos, lead, etc. Include date member was enrolled in and, if applicable, removed from the specific medical surveillance program(s). If unsure of which Medical Surveillance Programs service member is in, contact the Occupational Medicine (OM) Clinic (Ashore) or OM Point of Contact (Afloat) for your location. Ask the service member if they have any hearing problems or tinnitus (ringing in the ears). If they answer “yes” to either question, refer for a “Non-Hearing Conservation” audiogram

Section 9. Immunizations: Disregard this portion of the DD 2766; Using an approved immunization database verify that immunizations are current; record as per local automated process

Section 10. Readiness: Verify that a.-d. documented If automated, use printout instead. 10e.(1) Enter date, if on LIMDU or awaiting PEB. 10.e, (2) through (7): Disregard 10.f. Write optometry Rx if missing 10.i. Document clearance for PRT based on PARFQ and member interview Section 11. Deployment: Identify past deployments and verify completion of post-deployment and reassessment forms (DD 2796/DD2900) in the medical record; ask if member currently has deployment related health concerns

This page is simply a continuation sheet, And, finally, page 4. This page is simply a continuation sheet, which can be used for additional prevention screening tests.

NOTE: In addition to completing the DD Form 2766, these processes are also documented in AHLTA or on NAVMED 6120/4 April 2007