AF Form 1864: Perioperative Nursing Record | Download PDF

AF Form 1864: Perioperative Nursing Record | Download PDF – AF Form 1864, officially titled the Perioperative Nursing Record, is a standardized document used by the U.S. Air Force Medical Service (AFMS) to document comprehensive nursing care throughout the perioperative period. This includes preoperative assessment, intraoperative events, and postoperative recovery for patients undergoing surgical procedures in Air Force medical treatment facilities (MTFs).

The form ensures clear communication among the surgical team, supports quality assurance and risk management, and becomes a permanent part of the patient’s medical record. It aligns with DoD health record standards and is often referenced alongside DD Form 2005 (Privacy Act Statement – Health Care Records), which informs patients about the collection and use of their health information under the Privacy Act of 1974.

What Is AF Form 1864 Used For?

Perioperative nursing encompasses care before, during, and after surgery. AF Form 1864 serves as a vital tool to:

  • Record the patient’s preoperative assessment and wishes.
  • Document critical intraoperative details, such as positioning, skin integrity, counts, and safety measures.
  • Capture postoperative recovery observations in the Post-Anesthesia Care Unit (PACU) or equivalent.
  • Support continuity of care, legal documentation, and performance improvement activities in compliance with Joint Commission standards, AORN (Association of periOperative Registered Nurses) guidelines, and Air Force policies.

Military instructions, such as those from the 59th Medical Wing, describe it as a key document that communicates patient preferences to the surgical team while serving as an important quality assurance record. Once completed, the form is placed in the patient’s inpatient or ambulatory medical record.

It is listed in DoD health record guidance (DHA-PM 6025.02) among authorized forms for inpatient records, alongside items like the Operation Report and Anesthesia Recovery Record.

Key Sections and Content of AF Form 1864

While the exact layout is a multi-part form (typically one or more pages), it generally captures structured data across the perioperative phases:

  • Patient Identification and Administrative Data: Name, rank/grade, DoD ID or SSN (with Privacy Act protections via DD Form 2005), medical record number, date of surgery, procedure, surgeon, and anesthesia provider.
  • Preoperative Phase: Nursing assessment, allergies, vital signs, consent verification, skin condition, preoperative teaching, NPO status, and any special considerations or patient wishes.
  • Intraoperative Phase: Time in/out of OR, positioning, grounding/pad placement, skin prep, instrument/sponge/sharp counts, medications/fluids administered by nursing staff, implants, specimens, and any adverse events or deviations.
  • Postoperative Phase: Transfer to PACU, vital signs trends, pain assessment, airway status, consciousness level, dressings/drains, and discharge criteria from recovery.
  • Signatures and Verification: Circulating nurse, scrub technician, and other personnel sign off on counts, handoffs, and overall documentation.

Additional elements often include safety checklists (e.g., surgical site marking, time-out), latex/allergy precautions, and references to local instrument count records or incident reports (such as AF Form 765 if a count discrepancy occurs).

The form promotes standardized, legible documentation that reduces errors and supports audit trails in high-stakes surgical environments.

DD Form 2005: Privacy Act Statement Integration

DD Form 2005 provides the required Privacy Act notice for health care records. It explains the authority for collecting personal information (Title 10 U.S.C. sections on armed forces health care), principal purposes (providing treatment and managing records), and routine uses within the Military Health System (MHS).

This statement typically accompanies or precedes forms like AF Form 1864 that collect sensitive health data. It is not a consent for disclosure but ensures patients understand their rights and the protected nature of their information under HIPAA and DoD rules. Patients or sponsors sign to acknowledge receipt of the statement.

In Air Force practice, privacy and security of perioperative records are governed by AFI 33-332 (Air Force Privacy and Civil Liberties Program) and DoDM 6025.18 (HIPAA in DoD Health Care Programs).

How to Obtain and Use AF Form 1864?

  • Official Download: Access the current version directly from the Air Force e-Publishing site:
    https://static.e-publishing.af.mil/production/1/af_sg/form/af1864/af1864.pdf
  • Usage in MTFs: Perioperative nurses, circulating RNs, and surgical teams complete the form in accordance with local wing instructions, AFI 44-102 (Medical Care Management), and broader quality management policies (AFI 44-119). Electronic health record (EHR) systems may supplement or replace paper in some facilities, but the form remains a recognized standard.
  • Training and Competency: Air Force surgical service training materials reference AF Form 1864 in duties of scrub and circulating personnel, emphasizing its role in instrument counts and incident reporting.

Always follow your facility’s standard operating procedures (SOPs) and consult the latest Air Force Instructions (AFIs) or wing supplements for any updates.

Why Proper Documentation Matters in Air Force Perioperative Nursing?

Accurate completion of AF Form 1864 contributes to:

  • Patient safety and outcomes.
  • Compliance with accreditation bodies.
  • Risk management and medico-legal protection.
  • Seamless handoffs between preoperative holding, OR, and PACU teams.
  • Quality improvement data for the AFMS.

In deployed or expeditionary settings, similar documentation principles apply to maintain standards even in austere environments.

  • Air Force e-Publishing (Forms and Publications): e-publishing.af.mil
  • DoD Health Record Management: DHA Procedural Manual 6025.02
  • AORN Guidelines for Perioperative Practice (current edition)
  • Local MTF policies on informed consent and surgical services

Note: This article is for informational purposes only and does not replace official training, policy, or medical guidance. Always refer to the most current version of AF Form 1864 and applicable instructions from the Secretary of the Air Force or your medical wing.

For the official PDF, visit the link provided above. Medical personnel should complete required competencies in perioperative nursing per AFMS standards.

If you need guidance on filling specific sections or integrating with electronic systems, consult your facility’s perioperative educator or quality management team. Proper use of AF Form 1864 helps ensure every Airman and beneficiary receives safe, well-documented surgical care.