CompletingThe Adult Preventive and Chronic Care Flow Sheet

DD Form 2766

Rev Apr 07

These slides must be viewed in “Slide Show” view.

DD Form 2766• A Tri-service form

• Use for ADULTS

• Obtained through Navy Supply system

http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm

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

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

Atenolol 50 mg qdPremarin 0.625 mg qdProvera 2.5 mg qdFlonase 1 squirt ea nostril qd

HTN—Dx’d 1995Hypothyroidism—Hashimoto’sAllergic rhinitis

s/p appendectomy 1982s/p R breast biopsy 1995--benign

NKDA

1. Allergies Document medication and

environmental allergies.

3. Medications - list current Rx’s & OTC

medications

The remainder of page 1 must be completed in pen.

Only section 3 may be completed in pencil:

This is the top of page 1 of DD Form 2766. Every patient should have

pages 1 and 2 updated at every visit.

1/10/0057

F, N, I

3/17/0057

A—2/wkTo—none

AD Advance Directive

6/20/0057

AD

Jones Mary

30/123-45-6789

20 June 2000First, always ensure that the

patient’s identifying

information is entered.

To document counseling, simply enter the date, the patient’s age, and the codes for the topics that

were discussed.

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, it’s 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.

If you’re using a created code, ensure that it is included on the list of

codes and topics.

When an advance directive is filed in the chart (in

Section IV), enter the date here.

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).

On St. Patrick’s 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).

This is the bottom of page 1-- where counseling is documented.

200758

200859

200960

201061

201162

This is the top of page 2 of DD Form 2766.

200657

M—breast ca Dx’d at 48; F—colon ca Dx’d at 68

M—HTN, MI at 53

MGM—type 2 diabetes

S—major depression

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.When any test is performed,

enter the result in the appropriate cell.

After you’ve 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.

BP should be checked next year.

When entering the

family history, use

the relationship abbreviation

s that are defined on

the form (M, F, S, etc.). ...and the

codes can be found here!

132 / 86

Chol 122TG 21HDL 65LDL 53

14266”

But lipids don’t need to be checked for another 5

years.

For any other test, you may enter a code

for the result...

Enter any family history that is pertinent. For example,

since the age when her mother had her myocardial infarction (MI) is important,

enter the age.

The actual result must be entered for:

*weight*height*BP*cholesterol

3/15/07X--ASCUSrepeat3 mo

3/15/07pending

N

NR

This is the bottom of page 2—a continuation

of the Screening Exam section.

Note that “R” is a valid entry.

This patient was offered flexible sigmoidoscopy but refused it.

And note that she should be

offered it again next year. Only “X”

needed to be entered for

the Pap result. This provider opted to enter

more information.

Notice that, if a test was

ordered and the results are

pending, the entry should be in pencil. The

final result should be

entered—in pen—once it is available.

Section 8. Occupational History: Document monitoring programs, e.g. hearing conservation, radiological, lead, asbestos; Occupational screening

exams are highly dependent upon the patient’s 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

Section 9. Immunizations: Disregard this portion of the DD 2766;

Using an approved immunization databaseverify that immunizations are current; record

as per local automated process

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): Disregard10.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

And, finally, page 4. This page is simply a continuation sheet,

which can be used for additional prevention screening tests.

NOTE: In addition to completing the DD Form 2766, these processes are also documented in AHLTA or on NAVMED 6120/4

April 2007