DD Form 2526 Case Abstract for Malpractice Claims

DD Form 2526 or the "Case Abstract For Malpractice Claims" is a Department of Defense-issued form used by and within the United States Army.

The form - often mistakenly referred to as the DA form 2526 - was last revised on February 1, 2000. Download an up-to-date fillable PDF version of the DD 2526 down below or find it on the Department of Defense documentation website.

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1. DATE OF REPORT
2. CLAIMANT LAST NAME REPORT CONTROL SYMBOL
CASE ABSTRACT FOR
(YYYYMMDD)
DD-HA(AR)1782
MALPRACTICE CLAIMS
3. TYPE OF REPORT (X one)
4. DATES OF ACT(S) OR OMISSION(S) (YYYYMMDD)
a. BEGINNING DATE
b. ENDING DATE
a. INITIAL
b. CORRECTION OR ADDITION
c. REVISION TO ACTION
d. VOID PREVIOUS REPORT
5. DATE CLAIM FILED
6. DATE OF JUDGMENT OR
7. MEDICAL TREATMENT FACILITY
(YYYYMMDD)
SETTLEMENT
(YYYYMMDD)
a. NAME
b. DMIS CODE
8. PRACTITIONER INFORMATION
a. NAME (Last, First, Middle Initial)
b. SSN
c. DATE OF BIRTH (YYYYMMDD)
d. NAME OF PROFESSIONAL SCHOOL ATTENDED
e. DATE GRADUATED
f. SPECIALTY CODE
(YYYYMMDD)
g. STATUS (X one)
(9) Non-Personal
(1) Army
(3) Air Force
(5) Civilian GS
(7) Partnership External
Services Contract
(2) Navy
(4) PHS
(6) Partnership Internal
(8) Personal Services Contract
h. SOURCE OF ACCESSION (X all that apply)
(1) Military
(2) Civilian
(a) Volunteer
(d) National Guard
(a) Civil Service
(d) Foreign National (Local Hire)
(b) Armed Forces Health Pro-
(e) Reserve
(b) Contracted
(e) Other (Specify)
fessional Scholarship Program
(f) Other (Specify)
(c) Consultant
(c) Uniformed Services Univer-
sity of Health Sciences
i. LICENSING INFORMATION
(1) State of License
(2) License Number
(1) State of License
(2) License Number
9. TYPE OF PRACTITIONER AND SPECIALTY (FIELD OF LICENSURE) (X all that apply)
a. PHYSICIAN DEGREE
M.D. (010)
D.O. (020)
(1) Highest Level of Specialization
(a) Board Certified
(b) Residency Completed
(c) In Residency (015/025)
(d) No Residency
(2) Primary Specialty
(h) Internal Medicine (Cont.)
(l) Otorhinolaryngology
(t) Surgery, General (Cont.)
(a) In Training
(h.c) Infectious Disease
(m) Orthopedics
(t.d) Oncology
(b) General Practice (GMO)
(h.d) Nephrology
(n) Pathology
(t.e) Pediatric
(c) Anesthesiology
(h.e) Pulmonary
(o) Pediatrics
(t.f) Peripheral Vascular
(d) Aviation Medicine
(h.f) Rheumatology
(p) Physical Medicine
(t.g) Plastic
(e) Dermatology
(h.g) Tropical Medicine
(q) Preventive Medicine
(u) Underseas Medicine
(f) Emergency Medicine
(h.h) Allergy/Immunology
(r) Psychiatry
(v) Urology
(g) Family Practice
(h.i) Cardiology
(s) Radiology
(w) Intensivist
(h) Internal Medicine
(h.j) Endocrinology
(t) Surgery, General
(x) Neonatologist
(h.a) Gastroenterology
(i) Neurology
(t.a) Cardio-Thoracic
(y) Other (Specify)
(h.b) Hematology -
(j) Obstetrics/Gynecology
(t.b) Colon-Rectal
Oncology
(k) Ophthalmology
(t.c) Neurosurgery
(3) Board Certification(s)
b. DENTIST
DENTIST (030)
(1) Highest Level of Specialization
(2) Primary Specialty
(a) Board Certified
(c) In Residency (035)
(a) General Dental Officer
(c) Other (Specify)
(b) Residency Completed
(d) No Residency
(b) Oral Surgeon
(3) Board Certification(s)
c. OTHER PRACTITIONERS
OTHER PRACTITIONERS
Audiologist (400)
Nurse Anesthetist (110)
Optometrist (636)
Registered Nurse (100)
Clinical Dietician (200)
Nurse Midwife (120)
Physical Therapist (430)
Emergency Medical
Clinical Pharmacist (050)
Nurse Practitioner (130)
Physician Assistant (642)
Technician
Clinical Psychologist (370)
Occupational Therapist
Podiatrist (350)
Other (Specify)
Clinical Social Worker (300)
(410)
Speech Pathologist (450)
DD FORM 2526, FEB 2000
Page 1 of 4 Pages
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 7.0
1. DATE OF REPORT
2. CLAIMANT LAST NAME REPORT CONTROL SYMBOL
CASE ABSTRACT FOR
(YYYYMMDD)
DD-HA(AR)1782
MALPRACTICE CLAIMS
3. TYPE OF REPORT (X one)
4. DATES OF ACT(S) OR OMISSION(S) (YYYYMMDD)
a. BEGINNING DATE
b. ENDING DATE
a. INITIAL
b. CORRECTION OR ADDITION
c. REVISION TO ACTION
d. VOID PREVIOUS REPORT
5. DATE CLAIM FILED
6. DATE OF JUDGMENT OR
7. MEDICAL TREATMENT FACILITY
(YYYYMMDD)
SETTLEMENT
(YYYYMMDD)
a. NAME
b. DMIS CODE
8. PRACTITIONER INFORMATION
a. NAME (Last, First, Middle Initial)
b. SSN
c. DATE OF BIRTH (YYYYMMDD)
d. NAME OF PROFESSIONAL SCHOOL ATTENDED
e. DATE GRADUATED
f. SPECIALTY CODE
(YYYYMMDD)
g. STATUS (X one)
(9) Non-Personal
(1) Army
(3) Air Force
(5) Civilian GS
(7) Partnership External
Services Contract
(2) Navy
(4) PHS
(6) Partnership Internal
(8) Personal Services Contract
h. SOURCE OF ACCESSION (X all that apply)
(1) Military
(2) Civilian
(a) Volunteer
(d) National Guard
(a) Civil Service
(d) Foreign National (Local Hire)
(b) Armed Forces Health Pro-
(e) Reserve
(b) Contracted
(e) Other (Specify)
fessional Scholarship Program
(f) Other (Specify)
(c) Consultant
(c) Uniformed Services Univer-
sity of Health Sciences
i. LICENSING INFORMATION
(1) State of License
(2) License Number
(1) State of License
(2) License Number
9. TYPE OF PRACTITIONER AND SPECIALTY (FIELD OF LICENSURE) (X all that apply)
a. PHYSICIAN DEGREE
M.D. (010)
D.O. (020)
(1) Highest Level of Specialization
(a) Board Certified
(b) Residency Completed
(c) In Residency (015/025)
(d) No Residency
(2) Primary Specialty
(h) Internal Medicine (Cont.)
(l) Otorhinolaryngology
(t) Surgery, General (Cont.)
(a) In Training
(h.c) Infectious Disease
(m) Orthopedics
(t.d) Oncology
(b) General Practice (GMO)
(h.d) Nephrology
(n) Pathology
(t.e) Pediatric
(c) Anesthesiology
(h.e) Pulmonary
(o) Pediatrics
(t.f) Peripheral Vascular
(d) Aviation Medicine
(h.f) Rheumatology
(p) Physical Medicine
(t.g) Plastic
(e) Dermatology
(h.g) Tropical Medicine
(q) Preventive Medicine
(u) Underseas Medicine
(f) Emergency Medicine
(h.h) Allergy/Immunology
(r) Psychiatry
(v) Urology
(g) Family Practice
(h.i) Cardiology
(s) Radiology
(w) Intensivist
(h) Internal Medicine
(h.j) Endocrinology
(t) Surgery, General
(x) Neonatologist
(h.a) Gastroenterology
(i) Neurology
(t.a) Cardio-Thoracic
(y) Other (Specify)
(h.b) Hematology -
(j) Obstetrics/Gynecology
(t.b) Colon-Rectal
Oncology
(k) Ophthalmology
(t.c) Neurosurgery
(3) Board Certification(s)
b. DENTIST
DENTIST (030)
(1) Highest Level of Specialization
(2) Primary Specialty
(a) Board Certified
(c) In Residency (035)
(a) General Dental Officer
(c) Other (Specify)
(b) Residency Completed
(d) No Residency
(b) Oral Surgeon
(3) Board Certification(s)
c. OTHER PRACTITIONERS
OTHER PRACTITIONERS
Audiologist (400)
Nurse Anesthetist (110)
Optometrist (636)
Registered Nurse (100)
Clinical Dietician (200)
Nurse Midwife (120)
Physical Therapist (430)
Emergency Medical
Clinical Pharmacist (050)
Nurse Practitioner (130)
Physician Assistant (642)
Technician
Clinical Psychologist (370)
Occupational Therapist
Podiatrist (350)
Other (Specify)
Clinical Social Worker (300)
(410)
Speech Pathologist (450)
DD FORM 2526, FEB 2000
Page 1 of 4 Pages
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 7.0
10. PATIENT DEMOGRAPHICS
a. NAME (Last, First, Middle Initial)
c. AGE
b. SEX (X one)
(1) Male
(2) Female
(3) Unknown
e. SSN OF SPONSOR
d. STATUS (X and complete as applicable)
(1) Dependent of Active Duty
(3) Retired Member
(5) Active Duty
(2) Dependent of Retired Member
(4) Civilian Emergency
(6) Other (Specify)
11. DIAGNOSES
ICD9-CM CODE
12. PROCEDURES
ICD9-CM CODE
a. (Primary)
a. (Principal)
b.
b.
c.
c.
13. PATIENT ALLEGATION(S) OF NEGLIGENT CARE
a. DESCRIPTION OF THE ACTS OR OMISSIONS AND INJURIES UPON WHICH THE ACTION OR CLAIM WAS BASED (Limit to 300
characters.)
b. ACT OR OMISSION CODE(S) (Refer to table on Page 4)
c. CLINICAL SERVICE CODE
(1) Primary Act or Omission Code
(2) Additional Act or Omission Code
(1) Primary
(3) Additional Act or Omission Code
(4) Additional Act or Omission Code
(2) Secondary
(5) Additional Act or Omission Code
(6) Additional Act or Omission Code
(3) Tertiary
d. DESCRIPTION OF FINDINGS ON WHICH THE ACTION OR CLAIM WAS PAID
14. MALPRACTICE CLAIM MANAGEMENT
a. AMOUNT CLAIMED
b. ADJUDICATIVE BODY CASE NUMBER
c. ADJUDICATIVE
d. DATE OF PAYMENT
BODY NAME
(YYYYMMDD)
e. OUTCOME (X one)
(3) Denied: Statute of Limitations
(6) Litigated: Decision for Plaintiff
(1) Administratively Settled (Service)
(4) Denied: FERES
(7) Litigated: Decision for U.S.
(2) Denied: Dismissed by Plaintiff or
(5) Denied: Not a Legitimate Claim,
(8) Litigated: Out or Court Settlement (DOJ)
by Agreement
Non-Meritorious
(9) Other (Specify)
f. AMOUNT PAID
g. NUMBER OF CLAIMS FOR THIS INCIDENT
h. NUMBER OF PRACTITIONERS ON WHOSE BEHALF
PAYMENT WAS MADE
DD FORM 2526, FEB 2000
Page 2 of 4 Pages
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15. PROFESSIONAL REVIEW ASSESSMENT BY MEDICAL TREATMENT FACILITY
a. ATTRIBUTION OF CAUSE (X all that apply)
b. EVALUATION OF CARE (X one)
(3) Personnel other
(2) Not Met
(1) Facility or Equipment
(2) Physician
(1) Met
than Physician
(4) Management
(5) System
(3) Indeterminate
c. IDENTIFY LOCATION OF CARE (X one)
(1) Ambulatory
(2) Inpatient
(3) Dental
(4) Emergency
(5) Other (Specify)
Clinic
Clinic
Service
d. INJURY SEVERITY (X one)
e. INJURY DURATION (X one)
(1) None
(2) Some
(3) Death
(1) Temporary
(2) Permanent
(3) Cannot Predict/Undetermined
16. ASSESSMENT
YES
NO (Evaluation of Care. X one)
(1) Met
(2) Not Met
(3) Indeterminate
a. AFIP REQUIRED?
b. OTHER ASSESSMENTS
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
(1) Met
(2) Not Met
(3) Indeterminate
(1) UCA or Name
c. FINAL OTSG DETERMINATION ACT OR OMISSION CODE(S) (Refer to table on Page 4)
d. CLINICAL SERVICE CODE
(1) Primary Act or Omission Code
(2) Additional Act or Omission Code
(1) Primary
(3) Additional Act or Omission Code
(4) Additional Act or Omission Code
(2) Secondary
(5) Additional Act or Omission Code
(6) Additional Act or Omission Code
(3) Tertiary
MET
YES
17. STANDARD OF CARE (OTSG DETERMINATION)
18. NPDB REPORTED
(X one)
NOT MET
NO
19. REMARKS
DD FORM 2526, FEB 2000
Page 3 of 4 Pages
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*NOC = Not Otherwise Classified
20. ACT OR OMISSION CODES
DIAGNOSIS RELATED
OBSTETRICS RELATED
010
Failure to diagnose (i.e., concluding that patient has no
505
Failure to manage pregnancy
disease or condition)
510
Improper choice of delivery method
020
Wrong diagnosis (misdiagnosis, i.e., original diagnosis is
520
Improperly performed vaginal delivery
incorrect)
525
Improperly performed C-section
030
Improper performance of test
530
Delay in delivery (induction or surgery)
040
Unnecessary diagnostic test
540
Failure to obtain consent/lack of informed consent
050
Delay in diagnosis
550
Improperly managed labor (NOC)*
060
Failure to obtain consent/lack of informed consent
555
Failure to identify/treat fetal distress
560
Delay in treatment of fetal distress (i.e., identified but
090
Diagnosis related (NOC)*
treated in untimely manner)
ANESTHESIA RELATED
570
Retained foreign body/vaginal/uterine
580
Abandonment
110
Failure to complete patient assessment
590
Wrongful life/birth
120
Failure to monitor
590
Obstetrics related (NOC)*
130
Failure to test equipment
140
Improper choice of anesthesia agent or equipment
150
Improper technique/induction
TREATMENT RELATED
160
Improper equipment use
170
Improper intubation
610
Failure to treat
180
Improper positioning
620
Wrong treatment/procedure performed (also improper
185
Failure to obtain consent/lack of informed consent
choice)
190
Anesthesia related (NOC)*
630
Failure to instruct patient on self care
640
Improper performance of a treatment/procedure
SURGERY RELATED
650
Improper management of course of treatment
210
Failure to perform surgery
660
Unnecessary treatment
220
Improper positioning
665
Delay in treatment
230
Retained foreign body
670
Premature end of treatment (also abandonment)
240
Wrong body part
675
Failure to supervise treatment/procedure
250
Improper performance of surgery
260
Unnecessary surgery
680
Failure to obtain consent for treatment/lack of
270
Delay in surgery
informed consent
280
Improper management of surgical patient
685
Failure to refer/seek consultation
285
Failure to obtain consent for surgery/lack of informed
690
Treatment related (NOC)*
consent
290
Surgery related (NOC)*
MONITORING
MEDICATION RELATED
710
Failure to monitor
305
Failure to order appropriate medication
720
Failure to respond to patient
310
Wrong medication ordered
730
Failure to report on patient condition
315
Wrong dosage ordered of correct medication
790
Monitoring related (NOC)*
320
Failure to instruct on medication
325
Improper management of medication program
BIOMEDICAL EQUIPMENT/PRODUCT RELATED
330
Failure to obtain consent for medication/lack of
informed consent
810
Failure to inspect/monitor
340
Medication error (NOC)*
820
Improper maintenance
350
Failure to medicate
830
Improper use
355
Wrong medication administered
840
Failure to respond to warning
360
Wrong dosage administered
850
Failure to instruct patient on use of equipment/product
365
Wrong patient
860
Malfunction/failure
370
Wrong route
890
Biomedical equipment/product related (NOC)*
380
Improper technique
390
Medication administration related (NOC)*
MISCELLANEOUS
INTRAVENOUS AND BLOOD PRODUCTS RELATED
910
Inappropriate behavior of clinician (i.e., sexual
410
Failure to monitor
misconduct allegation, assault)
420
Wrong solution
920
Failure to protect third parties (i.e., failure to warn/
430
Improper performance
protect from violent patient behavior)
440
IV related (NOC)*
930
Breach of confidentiality/privacy
450
Failure to insure contamination free
940
Failure to maintain appropriate infection control
460
Wrong type
950
Failure to follow institutional policy or procedure
470
Improper administration
960
Other (Provide detailed written description)
480
Failure to obtain consent/lack of informed consent
990
Failure to review provider performance
490
Blood product related (NOC)*
DD FORM 2526, FEB 2000
Page 4 of 4 Pages

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