GSA Form SF-558 Medical Record - Emergency Care and Treatment

GSA Form STANDARD558 is a U.S. General Services Administration form also known as the "Medical Record - Emergency Care And Treatment". The latest edition of the form was released in September 1, 1996 and is available for digital filing.

Download an up-to-date GSA Form STANDARD558 in PDF-format down below or look it up on the U.S. General Services Administration Forms website.

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NSN 7540-01-075-3786
LOG NUMBER
TREATMENT FACILITY
EMERGENCY CARE
MEDICAL RECORD
AND TREATMENT
RECORDS MAINTAINED AT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION
ARRIVAL
STREET ADDRESS
DATE (Day, Month, Year)
TIME
TRANSPORTATION TO FACILITY
CITY
STATE
ZIP CODE
SEX
DUTY/LOCAL PHONE
MILITARY STATUS
THIRD PARTY INSURANCE
AREA CODE
NUMBER
ITEM
YES
NO
ITEM
YES
NO
N/A
PRP
ADDITIONAL INSURANCE
AGE
HOME PHONE
FLYING STATUS
DD 2568 IN CHART
AREA CODE
NUMBER
MEDICAL HISTORY OBTAINED FROM
NAME OF INSURANCE COMPANY
INJURY OR OCCUPATIONAL ILLNESS
EMERGENCY ROOM VISIT
CURRENT MEDICATIONS
WHEN (Date)
DATE LAST VISIT
24 HOUR RETURN
ITEM
YES
NO
YES
NO
WHERE
IS THIS AN INJURY?
TETANUS
ALLERGIES
DATE LAST SHOT
COMPLETED INITIAL SERIES
INJURY/SAFETY FORMS
HOW
YES
NO
CHIEF COMPLAINT
CATEGORY OF TREATMENT
VITAL SIGNS
TIME
TIME
EMERGENT
BP
PULSE
URGENT
INITIALS
RESP
TEMP
NON-URGENT
WT
CBC/DIFF
ABG
PT/PTT
BHCG/URINE/BLOOD/QUANT
CXR PA & LAT/PORTABLE
C-SPINE
CHEM:
ACUTE ABDOMEN
LS SPINE
URINE C&S
UA MSCC/CATH
HEAD CT
SINUS
BLOOD C&S X
ANKLE R/L
ORDERS
PULSE OX
MONITOR
ECG
TIME
ORDERS
BY
COMPLETED BY
TIME
PATIENT'S RESPONSE
DISPOSITION
DISPOSITION QUARTERS /OFF DUTY
PATIENT/DISCHARGE INSTRUCTIONS
HOME
FULL DUTY
24 HRS.
48 HRS.
78 HRS.
MODIFIED DUTY UNTIL
RETURN TO DUTY
CONDITION UPON RELEASE
ADMIT TO UNIT/SERVICE
TO
WHEN
REFERRED
IMPROVED
UNCHANGED
I have received and understand these instructions.
TIME OF RELEASE
DETERIORATED
PATIENT'S SIGNATURE
(For typed or written entries, give: Name -- last,
PATIENT'S IDENTIFICATION
first, middle; ID no. (SSN or other); hospital or
medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558
(REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.203(b)(10)
NSN 7540-01-075-3786
LOG NUMBER
TREATMENT FACILITY
EMERGENCY CARE
MEDICAL RECORD
AND TREATMENT
RECORDS MAINTAINED AT
(Patient)
PATIENT'S HOME ADDRESS OR DUTY STATION
ARRIVAL
STREET ADDRESS
DATE (Day, Month, Year)
TIME
TRANSPORTATION TO FACILITY
CITY
STATE
ZIP CODE
SEX
DUTY/LOCAL PHONE
MILITARY STATUS
THIRD PARTY INSURANCE
AREA CODE
NUMBER
ITEM
YES
NO
ITEM
YES
NO
N/A
PRP
ADDITIONAL INSURANCE
AGE
HOME PHONE
FLYING STATUS
DD 2568 IN CHART
AREA CODE
NUMBER
MEDICAL HISTORY OBTAINED FROM
NAME OF INSURANCE COMPANY
INJURY OR OCCUPATIONAL ILLNESS
EMERGENCY ROOM VISIT
CURRENT MEDICATIONS
WHEN (Date)
DATE LAST VISIT
24 HOUR RETURN
ITEM
YES
NO
YES
NO
WHERE
IS THIS AN INJURY?
TETANUS
ALLERGIES
DATE LAST SHOT
COMPLETED INITIAL SERIES
INJURY/SAFETY FORMS
HOW
YES
NO
CHIEF COMPLAINT
CATEGORY OF TREATMENT
VITAL SIGNS
TIME
TIME
EMERGENT
BP
PULSE
URGENT
INITIALS
RESP
TEMP
NON-URGENT
WT
CBC/DIFF
ABG
PT/PTT
BHCG/URINE/BLOOD/QUANT
CXR PA & LAT/PORTABLE
C-SPINE
CHEM:
ACUTE ABDOMEN
LS SPINE
URINE C&S
UA MSCC/CATH
HEAD CT
SINUS
BLOOD C&S X
ANKLE R/L
ORDERS
PULSE OX
MONITOR
ECG
TIME
ORDERS
BY
COMPLETED BY
TIME
PATIENT'S RESPONSE
DISPOSITION
DISPOSITION QUARTERS /OFF DUTY
PATIENT/DISCHARGE INSTRUCTIONS
HOME
FULL DUTY
24 HRS.
48 HRS.
78 HRS.
MODIFIED DUTY UNTIL
RETURN TO DUTY
CONDITION UPON RELEASE
ADMIT TO UNIT/SERVICE
TO
WHEN
REFERRED
IMPROVED
UNCHANGED
I have received and understand these instructions.
TIME OF RELEASE
DETERIORATED
PATIENT'S SIGNATURE
(For typed or written entries, give: Name -- last,
PATIENT'S IDENTIFICATION
first, middle; ID no. (SSN or other); hospital or
medical facility)
EMERGENCY CARE AND TREATMENT (Patient)
Medical Record
STANDARD FORM 558
(REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.203(b)(10)
NSN 7540-01-075-3786
TIME SEEN BY PROVIDER
EMERGENCY CARE AND TREATMENT
MEDICAL RECORD
(Doctor)
TEST RESULTS
WBC
Check if read by
ABG/PULSE OX
RADIOLOGY
radiologist
H/H
SUP 02
PH
P02
RESULTS
PCO2
SAT
OTHER
PLT
PT
DIP
EKG INTERPRETATION
APTT
BHCG
ETOH
GLU
MICRO
PROVIDER HISTORY/PHYSICAL
RESIDENT/MEDICAL STUDENT SIGNATURE AND STAMP
CONSULT WITH
TIME
ACTION
PROVIDER SIGNATURE AND STAMP
DIAGNOSIS
PATIENT'S IDENTIFICATION
(For typed or written entries, give: Name -- last, first, middle;
ID no. (SSN or other); hospital or medical facility)
EMERGENCY CARE AND TREATMENT (Doctor)
Medical Record
STANDARD FORM 558
(REV. 9-96)
Prescribed by GSA/ICMR
FPMR (41 CFR) 101-11.203(b)(10)

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