DA Form 5181 "Screening Note of Acute Medical Care"

What Is DA Form 5181?

This is a military form that was released by the U.S. Department of the Army (DA) on February 1, 2003. The form, often mistakenly referred to as the DD Form 5181, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

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SCREENING NOTE OF ACUTE MEDICAL CARE
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
TIME PATIENT DEPARTS UNIT
SCREENER LOCATION
(From DD Form 689)
TIME PATIENT ARRIVES
TIME ENCOUNTER BEGINS
TIME PATIENT LEAVES
DATE (YYYYMMDD)
SCREENER LOCATION
CHIEF COMPLAINT
DURATION
PATIENT RESIDENCE
VITAL SIGNS
(
) BARRACKS
(
) POST HOUSING
TEMPERATURE
ALLERGIES
(
) TRANSIENT
(
) OFF POST
PULSE
BP
RESP
FIRST VISIT FOR THIS COMPLAINT (
) YES (
) NO IF NO, WAS RETURN SCHEDULED/REQUESTED BY CARE PROVIDER?
(
) YES (
) NO
ALGORITHM/CODE
ALGORITHM/CODE
ALGORITHM SUMMARY
ALGORITHM SUMMARY
COMMENTS (Reasons for referral, method of referral, hospital appointments, self-care protocols, and patient instructions/precautions)
PATIENT'S IDENTIFICATION (Use mechanical imprint if available, for
FINAL DISPOSITION
typed or written entries give: Name, SSN, Unit, Sex, Birthdate and
(
) I - PHYSICIAN STAT
(
) IV - SELF CARE PROTOCOL
Duty Phone)
(
) II - PA STAT
(
) V - HOSP CLINIC REFERRAL
(
) III - PA
AIDMAN'S SIGNATURE & CODE
AUDITOR'S INITIALS &
DATE (YYYYMMDD)
APD LC v1.01ES
DA FORM 5181, FEB 2003
DA FORM 5181-R, OCT 86, IS OBSOLETE.
Page 1 of 2
SCREENING NOTE OF ACUTE MEDICAL CARE
For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General.
TIME PATIENT DEPARTS UNIT
SCREENER LOCATION
(From DD Form 689)
TIME PATIENT ARRIVES
TIME ENCOUNTER BEGINS
TIME PATIENT LEAVES
DATE (YYYYMMDD)
SCREENER LOCATION
CHIEF COMPLAINT
DURATION
PATIENT RESIDENCE
VITAL SIGNS
(
) BARRACKS
(
) POST HOUSING
TEMPERATURE
ALLERGIES
(
) TRANSIENT
(
) OFF POST
PULSE
BP
RESP
FIRST VISIT FOR THIS COMPLAINT (
) YES (
) NO IF NO, WAS RETURN SCHEDULED/REQUESTED BY CARE PROVIDER?
(
) YES (
) NO
ALGORITHM/CODE
ALGORITHM/CODE
ALGORITHM SUMMARY
ALGORITHM SUMMARY
COMMENTS (Reasons for referral, method of referral, hospital appointments, self-care protocols, and patient instructions/precautions)
PATIENT'S IDENTIFICATION (Use mechanical imprint if available, for
FINAL DISPOSITION
typed or written entries give: Name, SSN, Unit, Sex, Birthdate and
(
) I - PHYSICIAN STAT
(
) IV - SELF CARE PROTOCOL
Duty Phone)
(
) II - PA STAT
(
) V - HOSP CLINIC REFERRAL
(
) III - PA
AIDMAN'S SIGNATURE & CODE
AUDITOR'S INITIALS &
DATE (YYYYMMDD)
APD LC v1.01ES
DA FORM 5181, FEB 2003
DA FORM 5181-R, OCT 86, IS OBSOLETE.
Page 1 of 2
RECORD OF ACUTE MEDICAL CARE
(Entries on this record should be restricted to further evaluation and treatment of complaint(s) screened)
DATE (YYYYMMDD)
2ND CARE LOCATION
TIME PATIENT ARRIVES
TIME ENCOUNTER BEGINS
TIME PATIENT LEAVES
SIGNATURE OF MEDICAL SUPERVISOR
AUDITOR'S INITIALS AND DATE
SIGNATURE OF HEALTH CARE PROVIDER
(YYYYMMDD)
SPECIAL INSTRUCTIONS
This form will be utilized in lieu of SF 600 (Health Record-Chronological Record of Medical Care) at the BAS level and above
when care is initiated by an ADTMC screener. The record of acute, medical care will accompany the patient to the next level of
care or remain in the BAS depending on disposition reached. This form will be filed in the HREC when evaluation and audit are
completed.
APD LC v1.01ES
DA FORM 5181, FEB 2003
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