Completing The Adult Preventive and Chronic Care Flow

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/formsprogram. htm DD 2766 NSN 0102 -LF-984 -8400 DD 2766 C (cont. sheet) NSN 0102 -LF-984 -9600

DD Form 2766 • SECNAV 6120 (under revision) Periodic Health Assessment – Requires documentation on DD 2766 • 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

NKDA 3. Medications - list current Rx’s & OTC medications Atenolol 50 mg qd HTN—Dx’d 1995 Hypothyroidism—Hashimoto’s Allergic rhinitis Premarin 0. 625 mg qd Provera 2. 5 mg qd Flonase 1 squirt ea nostril qd 1. Allergies This is the top of Document medication and page 1 of Only section 3 DD Form 2766. environmental allergies. Every patient should have may be completed in pencil: pages 1 and 2 updated at every visit. s/p appendectomy 1982 s/p R breast biopsy 1995 --benign The remainder of page 1 must be completed in pen.

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

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

And note that she should be offered it again next year. Notice that, if a test was ordered Only “X” N and the results 3/15/07 needed to be pending are pending, the entered for the 3/15/07 entry should be X--ASCUS repeat Pap result. 3 mo in pencil. The This provider N final result R opted to Note that “R” is a enter should be more valid entry. This entered—in pen— patientinformation. was once it is offered flexible available. This is the bottom of sigmoidoscopy page 2—a continuation it. but refused 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. 10 e. (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/DD 2900) in the medical record; ask if member currently has deployment related health concerns

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