SOP/GO BYs for OSS and Separation Physicals

Purpose of Separation History and Physical Exam (SHPE):

• Facilitate the transfer of care from the DoD to the VA and support the evaluation of disability claims to include documentation of relevant ICD medical diagnosis codes within the EMR.

• Determine and document current health state in case of need for recall to active duty

  • Service members who qualify for a SHPE because of retirement or separation are presumed fit or retention, except for those previously determined unfit and continued in a permanent limited duty status per ManMed Ch 15-20-(2).

  • If determined unfit for active-duty service member is to be referred to Medical Review Board (MEB) and Disability Evaluation System (DES).

  • If a medical condition is detected at the time of the SHPE that would prevent a Service member from performing further duty if he or she were not separating, then the Service member will be referred for further evaluation and potential referral to the DES or IDES, in accordance with DoDI 1332.18. Conditions that do not preclude completion of service but that require documentation of medical profiles for administrative purposes shall be documented on the 2807.

• Ensure separating Service members have completed a separation exam when required (those serving > 30 consecutive days on active duty), within 90 days of separation date, either by completing a SHPE within a military treatment facility (MTF) or by DoD-contracted health care services, or by receiving notification and report of a VA performed exam intended to serve as a separation exam in support of a VA claim.

• If a Service member refuses or fails to comply with the processes necessary to complete the physical exam portion of the SHPE, the unit commander will be notified in accordance with Service guidance, and the refusal or compliance failure will be documented in a brief memo that is entered into the medical record system in lieu of the separation exam report.

Forms:

The SHPE / Retirement packet is put together by Jeff Sheggrud and is provided to the AD service member after they have received their separation/retirement orders. The packet contains the following documents:

• SF600: Chronological Record of Medical Care with MRRS review

• SF600: TBI Screening

• SF600: Mental Health Screening

• NAVMED 6224/8 (Rev 3-2011): Tuberculosis Exposure Risk Assessment

• DD Form 2807-1

• DD Form 2808

  • ICD-10: DOD0222

    • diagnosis code for a military services physical exam for termination is the FIRST diagnosis in EMR problem list

FORM DD 2807-1: Report of Medical History

• The Service member completes the DD Form 2807-1 (blocks 1-29) prior to scheduled appointment and the credentialed provider performing the face-to-face SHPE comments on all positive responses (except 14c) in block 30a; noting if member is considered disqualified (CD) or NOT considered disqualified (NCD) per ManMed Ch. 15 Section III. If member deemed NCD, then they are to be referred to DES.

• Provider stamps block 30b, signs block 30c and dates 30d with date completed

• An EMR medical encounter must be created and must refer to the DD 2807-1.

• The 2807 must be uploaded into the EMR.

• New diagnoses discovered in the SHPE not already listed on the Service member’s automated problem list must also be entered. Additional evaluation is not required unless the clinician determines that further care for the condition prior to separation is necessary.

FORM DD 2808-1: Report of Medical Exam:

The Service member completes the DD Form 2808 blocks 1-16, as well as the Name, SSN and DODID at the top of pages 2-3 prior to scheduled appointment and the credentialed provider performing the face-to-face SHPE will complete the remainder of the form to include the following:

• Blocks 17-44. Clinical Evaluation.

  • Blocks 17-44 are to be marked accordingly with abnormalities documented in block 44

    • Gender specific sensitive exams are not required unless medically indicated to meet standard of care. If not performed mark NE and document in block 44

• Block 49: HIV test result and date of test

• Block 52: Other – Hep C

• Blocks 53, 54, 57, and 58. Height, Weight, Pulse, Blood Pressure.

• Block 71: Audiogram. The audiogram does not need to be separately documented on DD Form 2808, if a recent audiogram (within 6 months of the SHPE) is documented in the EMR.

• Block 74: Document if member is or is not qualified for Separation / Retirement

  • If member is deemed NOT QUALIFIED then they are to sign block 75a and date 75b.

• Block 77: Summary of Defects and Diagnoses.

  • All diagnoses must be included in the problem list when the electronic record system is used.

• Block 78 and 79 require explanations OR it can be documented in EMR and in block 78/79 provider may write “See EMR”

  • Page 4 of 2808 is to be used for additional remarks regarding blocks 77-79 if elect to hand write medical diagnoses

• Block 82a/b: Stamp and Signature of Physician performing the SHPE

• The credentialed health care provider completes the DD Form 2808 and upon final signature the 2808 must be uploaded to the electronic medical

Timing of SHPE:

• A SHPE up to 30 days prior to the date of separation from active duty requires no further documentation.

• A SHPE up to 90 days prior to the date of separation from active duty must be validated as current not more than 30 days prior to the date of separation, consistent with separation processing procedures of the Military Department concerned. Such validation is an administrative requirement and does not require a separate entry into the medical record, though an entry may be made if necessary for tracking procedures.

• When conducted by the VA, a separation exam up to 180 days prior to the date of separation from active duty is acceptable. If SHPE performed by VA, then a DOD provider must review the VA performed exam and make an entry into the medical record noting agreeance. The presence of this entry must be validated as current no more than 30 days prior to the date of separation from active duty, consistent with separation processing procedures of the Military Department concerned.

• A DoD-performed physical examination may be accepted between 90 days and up to 12 months prior to the scheduled date of separation from active duty if it meets SHPE minimum standards, but a medical assessment must be completed no more than 30 days prior to separation from active duty and documented in the EMR.

• When a Service member has terminal leave, the final out-processing date may be used in lieu of date of separation from active duty for the timeline requirements given the consent of the Service member and approval of the Service member’s commander. When this is done, the Service member should be counseled to report to an MTF if new health conditions arise prior to the final date of separation. These requirements are documented with statements in the out-processing checklist.

Useful Dot Phrases:

HPI:

_ y/o AD_ presents for separation physical. Service Member at this time has no acute concerns. PMHx notable for _.

A/P:

ICD-10: DOD2022 – Separation Physical

Procedure Code - 96160 Review and assessment of forms. Documentation of assessment tool with scoring required.

_ y/o AD_ presents for separation physical. EMR and labs reviewed, 2807 and 2808 completed and no disqualifying conditions were noted. SHPE performed within _ days of scheduled separation and service member medically cleared for separation. See 2807/2808 for complete documentation.

Service member has been evaluated due to planned separation or retirement from active duty service. Service member has been found physically qualified to separate, which means that no medical condition has been noted that disqualifies the member from the performance of their duties or warrants disability evaluation system processing. To receive disability benefits from the Department of the Navy, member must be unfit to perform the duties of their office, grade, or rating because of a disease or injury incurred or exacerbated while in receipt of base pay. Some conditions, while not considered disqualifying for separation or retirement, may entitle member to benefits from the Department of Veteran’s Affairs. If member desires additional information regarding these benefits, contact the Department of Veteran’s Affairs at 1-800- 827-1000 or view the Web site at http://www.va.gov.

Purpose:

• Determine suitability of Navy and Marine Corps Service members and their family members, in receipt of orders to overseas by identifying special medical, dental, and educational requirements. This information is used to determine if a Service member or family member can successfully transfer to the assignment location indicated on the orders.

• Service members and family members with special medical and/or educational needs who are improperly screened can arrive at overseas, remote duty, or operational assignments with requirements beyond the capability of local medical, dental, educational, or community resources. This may result in increased absences from duty, decreased quality of life, early return from the assignment, billet gaps, and unplanned expenditures of temporary duty (TAD) or permanent change of station (PCS) funds. Proper screening reduces overall costs and ensures a productive tour for the Service member, family, and the command.

• Ensure each Service member is screened within 30 days of receipt of transfer orders or OSN, and each family member is screened within 60 days. Service members and family members will not transfer until satisfactory completion of the suitability screening process and issuance of official area clearance.

• A Service member and family member’s suitability/unsuitability for an overseas or remote duty assignment for Overseas is based on a gaining command review and the medical, dental, and educational suitability recommendation from the destination screening MTF.

• Provide the transferring command with a recommendation on a Service and family member’s suitability for an overseas or remote duty assignment by identifying and evaluating special medical and/or educational needs. Suitability recommendations are based on the capabilities to address the medical and/or educational needs at the gaining location

• During a scheduled medical appointment for routine medical care and/or a suitability screening, MTF staff members are required to identify family members with special medical and/or educational needs. In doing so eligible family members are identified and referred to the EFMP coordinator to initiate enrollment. Additionally, MTF providers must complete the DD Form 2792, Family Member Medical Summary, and refer to the EFMP coordinator immediately to initiate EFMP enrollment.

• Medical, dental, and educational suitability screening forms are valid for 12 months from the date of completion if there were no significant changes in the health or educational status of the Service member or family member.

Forms:

The OSS packet is put together by Mr. Dwayne Lockette, NHCP Overseas and Suitability Screening Coordinator (SSC) and is provided to the AD service member and dependents upon receipt of overseas orders. The packet contains the following documents:

• NAVMED 1300/2 (Rev 12-2015) – Medical, Dental, and Educational Suitability Checklist

  • For SSC, service member and family members; no physician documentation needed

• DD FORM 2807-1 – Report of Medical History

  • Physician review of page 1-2, documentation and signature required on page 3

• NAVMED 1300/1 (Rev. 1-2016) - Medical, Dental, and Educational Suitability Screening

  • Physician review part 1; documentation with signature on part 1, page 2

• NAVPERS 1300/16 (rev. 11-09) – Recommendation of Commanding Officer of MTF

  • For SSC, service member and family members; no physician documentation needed

FORM DD 2807-1: Report of Medical History

• The Service member or dependent completes the DD Form 2807-1 (blocks 1-29) prior to scheduled appointment and the credentialed provider performing the face-to-face OSS comments on all positive responses (except 14c) in block 30a.

• Provider reviews EMR for additional diagnoses the member emitted

• Provider stamps block 30b, signs block 30c and dates 30d with date completed

• An EMR medical encounter must be created and must refer to the DD 2807-1.

• The 2807 must be uploaded into the EMR.

NAVMED 1300/1 (Rev. 1-2016) - Medical, Dental, and Educational Suitability Screening

Part 1, section A. Medical Screening:

• Completed by the medical provider to identify special needs and determine if a service or family member is suitable for an overseas, remote duty or operational assignment.

• If marked “YES” in shaded block, then further description required in block 19

  • Shaded blocks are as follows:

    • 4b, 9, 10, 11c, 13, 14a-j, 15a-c, 16a-d, 17, 18, 19.

• NOTE*: In block 19 the Navy MTF SSC is not the physician performing the examination

Part 1, section B. Medical and Educational Screening Disposition

• Completed by the screening Navy MTF medical provider to determine is a service or family member is suitable for an overseas remote duty or operational assignment

• BLOCK 1: If “NO” on block 1 then skip 1.a and 1.b and move to block 2

• BLOCK 1: If “YES” on block 1 DO NOT PROCEDE / DO NOT SIGN document and tell member they need to return to SCC (Mr. Dwayne Lockette) for further review and way forward

• BLOCK 2: If “NO” on block 2 then skip 2.a and move to block 3

• BLOCK 2: If “YES” on block 2 DO NOT PROCEDE / DO NOT SIGN document and tell member they need to return to SCC (Mr. Dwayne Lockette) for further review and way forward

• If no shaded boxes in Section A were noted to be “yes” and blocks 1 and 2 in section B were both “NO” then fill out the Navy MTF Medical Screener block in bottom left corner

Part 2: Dental Screening

• To be performed by dentist, no physician signature required

Useful Dot Phrases:

HPI:

_ y/o _ presents for OSS physical with PCS orders to _. Member at this time has no acute concerns. PMHx notable for _.

A/P:

Z01.89 - Encounter for other specified special examinations

Procedure Code - 96160 Review and assessment of forms. Documentation of assessment tool with scoring required.

_ y/o _ presents for OSS with orders to _. Member’s EMR and medications reviewed, 2807 and NAVMED 1300/1 completed with no disqualifying conditions noted. As result member medically cleared and recommended for PCS to _. See 2807 and NAVMED 1300/1 for complete documentation.