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Fillable Form DA 7809

SUMMARY OF CARE BY NON-MILITARY MEDICAL PROVIDER

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What is Form DA-7809?

soldier issuing da-7809

Form DA-7809 is a document used by the United States Department of Defense (DoD) for the purpose of recording and reporting medical treatment provided to military personnel. By documenting this information, the form facilitates continuity of care and enables healthcare providers to track the progress of a service member's medical condition over time.

DA Form 7809 also serves as a communication tool between healthcare providers within the military healthcare system. When a service member receives treatment from multiple providers or moves between different medical facilities, the form allows for smooth transfer of medical information, especially from a military to non military medical provider. This is important for all parties involved, as it means that even if the patient is or was stationed overseas and received treatment there, any healthcare provider will have the information they need to continue their treatment as planned, minimizing risk to the patient and ensuring that the healthcare provider is able to give the appropriate care.

How do I fill out Form DA-7809?

Get a copy of DA 7809 template in PDF format.

soldiers discussing contents of da-7809

You may find a fillable template for Form DA-7809 here. Forms such as the DA Form 7809 can often be saved in the PDF format and printed later as necessary. Make sure to store these documents as needed to comply with filing and essential document standards.

Section I - Patient Data

Name

Enter the patient’s name.

Patient Home Address

Enter the patient’s home address.

DOD ID Number

Enter the patient’s DOD ID Number.

Rank/Grade

Enter the patient’s Rank and Grade.

DOB

Enter the patient’s Date of Birth.

Phone Number

Enter the patient’s primary phone number. Include the area code.

Component

Mark the box that corresponds to what component the patient belongs to. You may choose from among the following:

  • AC
  • ARNG
    • AGR
    • IDT/M-Day
    • ING
  • USAR
    • AGR
    • TPU
    • IMA
    • IRR

Disability Benefits

Check “Yes” or “No” to indicate whether or not the patient is receiving any VA disability benefits. If “Yes”, list all medical conditions with an overall rating % in the space provided.

Section II - Exam

Soldier Assessment

Mark the box provided if the patient was being assessed for their Periodic Health Assessment (PHA). Then enter the reason for why the patient was examined.

Test Results

Attach any lab and x-ray results to this form, then provide a brief summary of physical, radiological, and lab exam findings in the space provided, if/when they are available. Mark the box provided if the pertinent documentation is already attached to the patient’s PHA record.

Allergies

If the patient has any allergies to medications, food, insects, plants, or other things, list them in the space provided.

Medications

If the patient will need to or is currently taking medication, whether prescription, over the counter, vitamin/mineral, or supplement, list all of these that they are taking in the space provided.

Section III - Diagnosis

For each of the below, mark the box provided if, and only if, the patient has been diagnosed with the corresponding item. Mark all of the following that the patient has been diagnosed with:

  1. ADD/ADHD
  2. Anxiety
  3. Arthritis/Joint Pain
  4. Asthma/Shortness of Breath
  5. Concussion/TBI/Head Trauma
  6. Depression
  7. Diabetes/High blood sugar
  8. Dizziness
  9. Fainting
  10. Headaches/Migraines
  11. High blood pressure
  12. High cholestrol
  13. Insomnia
  14. PTSD
  15. Seizures
  16. Sleep apnea
  17. Other (Enter any additional and pertinent information about the patient’s medical history, past surgeries, and so on)

Section IV - Functional Activities

Mark “Yes” or “No” to indicate whether or not the patient is fit to engage the following activity(ies), both physically and mentally:

  • Carry and fire an individual assigned weapon that requires crouching, kneeling on one or both knees, lying prone or standing all while wearing a helmet, body armor, and load-bearing equipment
  • Ride in a military vehicle wearing helmet, body armor, and load-bearing equipment
  • Wear helmet, body armor, and load bearing equipment
  • Wear a protective mask and full protection outfit (HAZMAT) against chemical or biologic agents for at least 2 continuous hours per day
  • Move greater than 40Ibs while wearing a helmet, body armor, and load-bearing equipment up to 100 yards
  • Live and function, without restrictions, in any geographical or climatic area
  • Lifting/Carrying restriction (enter the amount that the patient will be allowed to lift and carry in the space provided, if applicable)
  • Standing limitation (enter the amount of time in minutes that the patient may stay standing up in the space provided, if applicable)
  • Walking limitations/Restriction in all terrains with standard field gear (enter the amount of time and the number of miles that the patient will be allowed to travel while carrying standard field gear, if applicable)

Army Physical Fitness Test (APFT) Events

Mark “Yes” or “No” to indicate whether or not the patient is fit to engage the following activity(ies), both physically and mentally:

  • Two minute timed sit-ups
  • Two minute timed push-ups
  • Times 2-mile run
    • If No, mark all the boxes from below that apply to what the patient may participate in.
      • 2.5 mile timed walk
      • 6.2 mile timed stationary bike
      • 800 yard timed swim

Section V - Diagnosis

Diagnosis

Enter the diagnosis of the patient.

Treatment Plan

Enter an outline of the patient’s treatment plan.

Follow-Up

Enter the date and purpose of any follow-up checkups the patient will have to attend.

Functional Limitations

Mark the box that indicates whether the limitations as placed in Section IV are permanent or temporary. If the limitations are temporary, enter the number of days that the limitation is expected to last for.

Then, mark the box that indicates whether or not the patient may take the AFPT now, or if it must be taken during a different date. If the patient must take the AFPT at a later date, enter the expected date that they should be able to take the AFPT.

Medical Provider’s Information

Enter the following information about the medical provider that examined the patient.

  • Full name
  • Medical degree
  • Specialty
  • Date of Evaluation
  • Email Address
  • Office Phone Number
  • Fax Number

Medical Provider’s Signature

Have the medical provider sign the form in the space provided, then enter the date that the form was signed.

Continuation

Use this space to complete any response from the previous sections that you did not have enough room to finish on that page.

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Frequently Asked Questions (FAQs)

How does Form DA-7809 support continuity of care?

By documenting medical treatment, the form allows for seamless transfer of information between healthcare providers.

How does Form DA-7809 contribute to compliance with standards of practice?

The form helps military medical facilities adhere to standards of practice by documenting patient care.

What can aggregated data from Form DA-7809 be used for?

Aggregated data can be used for assessing medical conditions among service members, identifying trends, and evaluating interventions.

Who has access to the information recorded on Form DA-7809?

Authorized healthcare providers and personnel involved in the patient's care can access the information.

Why is it important to document prescribed medications on Form DA-7809?

Documenting medications ensures accurate tracking of treatment and helps prevent adverse drug interactions.

Can Form DA-7809 be used for retrospective analysis?

Yes, the recorded information can be used for retrospective analysis of medical treatment provided.

How does Form DA-7809 ensure privacy and confidentiality of patient information?

In compliance with the Privacy Act of 1984, access to the form is restricted to authorized personnel, and measures are in place to safeguard patient confidentiality. No one outside of the patient’s doctor and those they choose to inform or grant access to their records may access Form DA-7809.

How often should Form DA-7809 be updated?

The form should be updated whenever medical treatment is provided to ensure that the information remains current and accurate. Filling out the form should also be prioritized before deployment or other major events that may impact the patient’s functional abilities.

How long are Form DA-7809 records retained?

Form DA-7809 records are retained in accordance with applicable regulations and retention policies.

Can Form DA-7809 be used for tracking trends in healthcare utilization?

Yes, aggregated data from the form can be analyzed to identify trends in healthcare utilization among military personnel.

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