DA Form 3647-1: Inpatient Treatment Record Cover Sheet – DA Form 3647-1 is the Inpatient Treatment Record Cover Sheet (For Plate Imprinting) used by the U.S. Army. It serves as the official cover and summary sheet for inpatient medical records in military treatment facilities (MTFs).
This specialized version supports plate imprinting for efficient data entry of patient identification details. It summarizes key admission, treatment, disposition, and administrative data for each inpatient episode. Healthcare providers use it alongside related forms like the standard DA Form 3647.
Download the official DA Form 3647-1 here: https://armypubs.army.mil/pub/eforms/DR_a/ARN43143-DA_FORM_3647-1-001-EFILE-2.pdf
Purpose and Regulatory Guidance
For use of this form, see AR 40-400 (or successor regulations such as AR 40-66 for medical record administration). The proponent agency is the Office of The Surgeon General.
The form ensures standardized documentation of inpatient care, supports patient accountability, facilitates medical record maintenance, and aids in statistical reporting and continuity of care across military healthcare systems. It is prepared as an original and copies for each admitted patient or carded-for-record-only (CRO) case.
Key Features of DA Form 3647-1
- Plate Imprinting Design: Optimized for addressograph plate or similar mechanical imprinting of patient data (name, rank, SSN, etc.).
- Comprehensive Data Fields: Covers patient demographics, admission details, diagnoses, disposition, and administrative statistics.
- Multi-Part Set: Typically produced as a four-part set for distribution within the medical record and administrative channels.
- Version Details: Current edition dated 1 May 1979; earlier editions (e.g., 1 Aug 1976) are obsolete.
It works with modern systems like CHCS (Composite Health Care System) where applicable, though the paper form remains essential for certain inpatient jacket requirements.
How to Fill Out DA Form 3647-1: Step-by-Step Guide?
Patient Data Items 1-30 (Excluding 25 & 26)
These fields capture core identification and admission information:
- Register number, name, grade/rank
- Sex, age, race, religion
- SSN, organization, ward
- Date of admission, source and authority
- Emergency addressee and contact details
- Medical treatment facility information
Imprint patient data using the plate where possible for accuracy and speed.
Items 25-26: Disposition
- Type of Disposition (e.g., discharged, transferred, died)
- Date of Disposition
Item 31: Selected Administrative Data
Includes details such as units of blood/components transfused and other administrative notes.
Item 33: Cause of Injury
Document the cause (e.g., accident, combat, illness).
Item 34: Diagnoses/Operations and Special Procedures
List principal and secondary diagnoses, surgical procedures, and notable interventions.
Days and Statistics (Item 35-36)
- Total days at this facility (absent sick, other, etc.)
- Total days across all facilities
- Categories include bed days, convalescent leave/coop care days, supplemental care days, and total sick days.
Signatures Required:
- Admitting Officer
- Attending Medical Officer
- PAD or Medical Records Officer
Always check “Continued on Reverse” if additional space is needed.
When and Where DA Form 3647-1 Is Used?
- For every inpatient admission to Army MTFs (hospitals, fixed health clinics).
- Live births, NATO personnel, and carded-for-record-only cases.
- Part of the official Inpatient Treatment Record (Clinical Record) jacket.
- Filed in the patient’s permanent medical record upon discharge or transfer.
U.S. Army medical records administrators, attending physicians, and patient administration personnel (PAD) primarily handle this form.
Differences Between DA Form 3647 and DA Form 3647-1
- DA Form 3647: Standard version, often for typed or computer-generated entries.
- DA Form 3647-1: Specifically designed for plate imprinting, with layout optimized for mechanical data transfer.
Both serve similar purposes but the -1 variant streamlines high-volume admission processes in busy military hospitals.
Download and Access Official DA Form 3647-1
Official PDF Download (Army Publishing Directorate):
DA Form 3647-1 PDF
Fillable versions are available on authorized Army sites and trusted form repositories. Always use the latest official edition from armypubs.army.mil for compliance.
Best Practices and Compliance Tips (USA Military Context)
- Follow current AR 40-66 or DHA guidance for medical record administration.
- Ensure all entries are legible, accurate, and properly countersigned.
- Maintain HIPAA-equivalent privacy and security standards for protected health information.
- Use in conjunction with electronic health record systems where available.
- Retain and dispose of records according to Army and DoD retention policies.
Proper completion supports seamless care transitions, medical readiness tracking, and administrative accuracy for service members and their families.
This article is for informational purposes and references official U.S. Army publications. For official guidance, consult your medical records administrator or the latest Army regulations.