DA Form 4107: Operation Request and Worksheet Guide – U.S. Army medical professionals use DA Form 4107 (Operation Request and Worksheet), dated March 1982, as a key document for requesting, scheduling, and documenting surgical procedures and related treatments in military treatment facilities (MTFs). AR 40-66 governs its use.
Download the official DA Form 4107 here: https://armypubs.army.mil/pub/eforms/DR_a/pdf/A4107.pdf
This article covers the purpose, sections, completion instructions, and best practices for this essential Army medical form.
What Is DA Form 4107?
DA Form 4107, titled Operation Request and Worksheet, serves as both a request tool for scheduling operations and a worksheet for recording intraoperative details. The medical or dental officer responsible for the patient initiates Section A. Anesthesia or nursing personnel complete Section B.
It applies to procedures in main operating rooms, ambulatory surgery centers, and situations requiring anesthesia or OR nursing support (such as obstetrics, special procedures in radiology, or cardiac catheterization).
Key Facts:
- Edition: March 1982 (Edition of 1 Jun 73 may be used).
- Proponent: Office of The Surgeon General.
- Reference: AR 40-66, Medical Record Administration and Healthcare Documentation.
- Purpose: Ensure accurate scheduling, resource allocation, patient safety, and complete documentation for surgical cases.
Purpose of DA Form 4107 in Army Medical Operations
The form standardizes communication between requesting providers, surgeons, anesthesiologists, and operating room staff. It helps:
- Schedule cases by priority (Emergency, Semi-Emergency, Routine).
- Document preoperative details, required resources (blood, staff, equipment), and special instructions.
- Record actual procedure details, anesthesia, complications, and postoperative information.
- Support accurate entry into the Register of Operations (DA Form 4108) and overall medical recordkeeping.
Accurate completion improves patient safety, OR efficiency, and compliance with Army medical standards.
Section A: Request for Surgery – Step-by-Step Guide
The requesting medical or dental officer primarily completes Section A (except items 20 and 21).
Common fields include:
- Patient Information (Items 1-6): Name, status, age, religion, register number, SSN.
- Preoperative Diagnosis (Item 7) and Proposed Operation (Item 9).
- Nursing Unit, Requesting Service, Date/Time of Surgery, Case Priority, Blood Required.
- Septic (Item 15): Indicate “yes” if purulent material or infectious conditions are present/anticipated.
- Surgeon, Assistants, Patient Position, Prep Required.
- Special Instructions and Remarks (Item 23): Include prep solutions or other needs.
- Requesting Officer Signature (Item 24).
Item 20 (Nursing Staff): Completed by Chief, Operating Room Nursing Section or designee (scrub and circulator names).
Item 21 (Anesthetist(s)): Completed by Chief of Anesthesia or designee.
Item 22: Type of anesthesia desired (general, regional, local, topical).
Section B: Operation Worksheet – Intraoperative Documentation
Section B captures real-time details during the procedure. The anesthesiologist, nurse anesthetist, or designated nursing personnel complete it.
Key elements:
- Operating Room No., Time/Case No., Septic status, Fluids, Blood administered.
- Surgeon, Assistants, Anesthetist(s), Anesthesia start/end times.
- Anesthetic agents, techniques, airway management, relaxants, special procedures.
- Nursing times, scrubbed and circulating personnel.
- Operation date/time, drains, sponge count, laboratory specimens.
- Operative Diagnosis, Operations Performed, Complications (use reverse if needed).
- Dictator’s name/service/phone and recording initials.
This section ensures comprehensive records for quality review, billing, and legal/medical continuity.
How to Fill Out DA Form 4107: Best Practices?
- Be Accurate and Legible — Use permanent ink or approved electronic methods. Errors can affect scheduling and patient safety.
- Coordinate Early — Requesting provider completes most of Section A in advance.
- Indicate Priority Clearly — Emergency cases receive immediate attention.
- Document Infections — Always note septic conditions for OR preparation and infection control.
- Include All Special Needs — Blood products, equipment, positioning, or prep solutions.
- Complete Post-Procedure — Fill Section B promptly for accurate records.
- Link to Other Forms — Use with consent forms (e.g., OF 522), anesthesia records, and OR schedules (DA Form 7001).
Tip for U.S. Army Medical Facilities: Check local MTF SOPs, as some use electronic systems (e.g., AHLTA) that may supplement or replace paper forms while maintaining required data elements.
Who Uses DA Form 4107?
- Surgeons and requesting physicians/dentists.
- Anesthesiologists and nurse anesthetists.
- Operating Room nursing staff.
- Medical records administrators in Army hospitals and clinics.
It primarily supports active duty, dependents, and other authorized beneficiaries in Army Medical Treatment Facilities.
Why Proper Use of DA Form 4107 Matters?
Accurate use of this form supports:
- Patient Safety — Clear communication reduces errors.
- Regulatory Compliance — Meets AR 40-66 requirements.
- Operational Efficiency — Better OR scheduling and resource use.
- Quality Improvement — Detailed records aid reviews and audits.
- Legal Protection — Thorough documentation protects providers and the Army.
Download and Access DA Form 4107
Official Fillable PDF: Download DA Form 4107 from Army Publishing Directorate
Always use the latest version from armypubs.army.mil for official use. Local MTFs may provide electronic templates or integrated systems.
For additional guidance, consult AR 40-66 or your facility’s medical records or operating room department.
This guide is for informational purposes and based on official Army sources. Always follow current regulations and local policies for official use.