Completing The Adult Preventive and Chronic Care Flow Sheet

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CompletingThe Adult Preventive and Chronic Care
Flow Sheet

• DD Form 2766

Rev Apr 07
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These slides must be viewed in Slide Show view.
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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/f
  ormsprogram.htm

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

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3. Medications - list current Rxs OTC
medications
NKDA
Atenolol 50 mg qd Premarin 0.625 mg qd Provera
2.5 mg qd Flonase 1 squirt ea nostril qd
HTNDxd 1995 HypothyroidismHashimotos 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.
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This is the bottom of page 1-- where counseling
is documented.
To document counseling, simply enter the date,
the patients age, and the codes for the topics
that were discussed.
On St. Patricks 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, its 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 patients
identifying information is entered.
If youre 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.
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After youve 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.
For any other test, you may enter a code for
the result...
When any test is performed, enter the result in
the appropriate cell.
2006 57
This is the top of page 2 of DD Form 2766.
...and the codes can be found here!
BP should be checked next year.
But lipids dont need to be checked for another 5
years.
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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 enteredin
penonce 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 2a continuation of
the Screening Exam section.
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Section 8. Occupational History Document
monitoring programs, e.g. hearing conservation,
radiological, lead, asbestos Occupational
screening exams are highly dependent upon the
patients 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
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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
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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
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And, finally, page 4. This page is simply a
continuation sheet, which can be used for
additional prevention screening tests.
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NOTE In addition to completing the DD Form
2766, these processes are also documented in
AHLTA or on NAVMED 6120/4
April 2007