DA Form 3647-1. Inpatient Treatment Record Cover Sheet (For Plate Imprinting)

Form DA 3647-1 is a variant of the Inpatient Treatment Record Cover Sheet specifically designed for plate imprinting purposes within a military medical facility. This form serves the same function as the standard DA 3647 form but includes additional space for plate imprinting.

The form consists of sections where the patient's personal information, medical facility details, and treatment episode information can be recorded. It may include sections for documenting the patient's admission and discharge dates, primary diagnosis, attending physician, and any significant medical events or procedures during the treatment period. Additionally, it provides space for plate imprinting, which allows for the transfer of information onto a metal plate for long-term record storage.

Important fields in this form include the patient's personal information, treatment episode details such as admission and discharge dates, primary diagnosis, attending physician, and any significant medical events or procedures. The plate imprinting section is used to create a permanent record of the cover sheet for archival purposes.

Application Example: Military medical facilities can use this form as a cover sheet for organizing and summarizing the contents of an inpatient treatment record while also creating a plate imprint for long-term record storage. The form should be completed with accurate and complete information about the patient, treatment episode, and any relevant medical events or procedures. This form helps facilitate efficient management, retrieval, and long-term preservation of inpatient medical records within the military healthcare system.

Related Forms: Form DA 3647 is the standard Inpatient Treatment Record Cover Sheet without the plate imprinting section.