110 AFMAN41-210 10 SEPTEMBER 2019
5.4.10.4.6.1. Air Force Service Treatment Record Processing Center: The AFMS
has opted to centralize the Service Treatment Record digitization, for
retiring/separating members, into HAIMS for access by the VA. The Service
Treatment Record disposition process can be found in this manual in paragraph 5.7.
5.4.10.4.6.2. The home MTF/Dental Treatment Facility is responsible for securing
the service member’s paper Service Treatment Record, collecting all unfiled, loose
and late flowing documents and artifacts at the MTF and filing them properly in the
Service Treatment Record. This does not include electronic encounter information
maintained in AHLTA. Any loose and late flowing documents will be scanned and
uploaded into HAIMS by the MTF.
5.5. Electronically-Generated Forms.
5.5.1. Use only the Air Force-approved forms package. Word processing packages are
directly forbidden because there is no method of locking the form so that it cannot be changed
by the user. See AFI 33-360. Most Air Force, Standard Forms (SF) and Optional Forms (OFs)
can be obtained from the Air Force e-Publishing website at: http://www.e-publishing.af.mil.
5.5.2. The only exception to the rule in 5.5.1 is permission to use the forms for which
AFMOA/SGAT has identified standard data elements. For these forms, the standard elements
are required but mirror imaging of the paper form is no longer required. (T-1). Additional data
elements that would change the meaning of the form cannot be added. Standard patient
information is required on these forms.
5.5.3. Include the following patient information blocks on both inpatient and outpatient forms:
Name (last, first, middle), patient family member prefix/last four digits of the sponsor’s social
security number, DoD Identification Number, Sex, Date of Birth, Rank/Grade,
Department/Service Where Records Maintained, and Relationship to Sponsor. Under Sponsor
Information, include Name (last, first, middle) and last four digits of the Sponsors Social
security number and/or DoD Identification Number. Under Facility Information, include
Name of MTF. Additionally, add blocks for Register Number and Ward Number on inpatient
forms.
5.5.4. To date, the forms for which standard data elements have been identified for the body
of the form are: SF 93, Report of Medical History, SF 505, Medical Record – History Parts 2
and 3, SF 506, Medical Record – Physical Examination, SF 509, Medical Record – Progress
Report, SF 526, Medical Record – Interstitial/Intercavitary Therapy, SF 551, Medical Record
– Serology, SF 558, Medical Record – Emergency Care and Treatment, SF 559, Medical
Record – Allergen Extract Prescription – New and Refill, SF 600, and OF 523B. Contact
AFMOA/SGAT for a list of the identified standard data elements for these and any subsequent
forms for which standard data elements have been identified.
5.5.5. OF 275, Medical Record Report, may be used in lieu of SFs, Air Force forms and DoD
forms, available at https://www.gsa.gov/forms-library/medical-record-report. OF 275, if
used, must indicate the form number and title of the form being replaced. (T-3). Information
entered on the form must include all of the same information as the form it represents. (T-2).
Scan and upload the OF 275 into the patient’s electronic health record. This form is not to be
used for the creation of local forms.