4.1 Military Treatment Records Flashcards
LIST the purposes of the military treatment record:
What is the purpose of the Military
Treatment Record?
Chronological record of medical treatment afforded members of the naval service.
LIST the purposes of the military treatment record:
The Medical Treatment Record has a current and long-term medico-legal value to who?
The individual concerned,
Their survivors,
U.S. Government.
LIST the purposes of the military treatment record:
Health Records (HRECs) are used to plan patient care and evaluate what?
The patient’s condition and treatment.
Purposes of the military treatment record:
Health Records (HRECs) are used to furnish documentary evidence over the course of the patient’s?
Medical evaluation,
Treatment,
Change in condition.
Purposes of the military treatment record:
Health Records (HRECs) are used to document communication between who?
Those who contribute to the patient’s care,
The practitioner responsible for the patient,
And all other health care professionals (HPs).
Purposes of the military treatment record:
Health Records (HRECs) are used to
assist in protecting the legal interest of who?
The patient,
The Medical Treatment Facility (MTF),
Dental Treatment Facility (DTF),
The practitioner responsible for the patient,
The USN,
The U.S. Government.
Purposes of the military treatment record:
Health Records (HRECs) are used to provide data for use in what?
Continuing education and research.
Purposes of the military treatment record:
Health Records (HRECs) are used to justify costs incurred by who?
Third party payers.
Purposes of the military treatment record:
Health Records (HRECs) are used to serve as a vehicle of communication among who?
Health care providers,
Utilization management,
Risk management,
Quality assurance,
Medical records personnel,
Outside agencies.
Opening Military Treatment Records:
When is a new health record (HREC) opened?
Upon initial entry of a member into the Regular or Reserve naval service.
Opening Military Treatment Records:
Where can a new medical record be opened initially?
MEPS.
Opening Military Treatment Records:
A separate dental treatment record (DREC) is prepared when?
At the time of the first dental visit.
Opening Military Treatment Records:
For individuals who have had prior service and have been discharged,
Order their HREC and DREC from where?
The National Personnel Records Center.
LIST the occasions when the treatment record is opened and closed:
For individuals who have had prior service and have been discharged,
Order their HREC and DREC from the National Personnel Records Center using what form?
DD 877,
Request for Medical/ Dental Records.
LIST the occasions when the treatment record is opened and closed:
When a midshipmen or enlisted member is appointed to commissioned or warrant grade,
What happens to their existing HREC?
It will still be in use,
Make necessary entries to indicate new grade.
LIST the occasions when the treatment record is opened and closed:
When a midshipmen or enlisted member is appointed to commissioned or warrant grade,
Prepare Additional summary information entries on what forms?
SF 600 and NAVMED 6150/4.
Opening Military Treatment Records
Midshipmen/Enlisted Update:
What information is documented on SF 600 and NAVMED 6150/4?
Date,
Place,
Grade.
Closing Military Treatment Records:
When is a military health treatment record (HREC) closed?
Dies/declared dead,
Is discharged,
Resigns (Officers ONLY),
Is released from active duty,
Retires,
Is transferred to the Fleet Reserve and released to inactive duty,
Is declared missing or missing in action,
Is declared a deserter,
Is dis-enrolled from officer candidate or midshipman programs.
Closing Military Treatment Records:
When closing a medical record,
Record the closing entries on what form?
NAVMED 6150/4,
Abstract of Service and Medical History.
Closing Military Treatment Records:
When closing out a medical record,
What information needs to be included?
Date of separation,
Title of servicing activity,
Any explanatory circumstances.
Closing Military Treatment Records:
When closing a health record, the record needs to be organized and neat,
What are the ways to accomplish this?
In order,
No loose papers,
All identification data is consistent,
Ensure all pertinent documents are included.
Closing Military Treatment Records:
After closing the health record,
Deliver the entire health record, except as otherwise noted,
To where?
The command maintaining the member’s service record.
Closing Military Treatment Records:
How long do you have to deliver a medical record to the command after closing it?
No later than a day, following separation,
For inclusion in and transmittal with the member’s service record.
Closing Military Treatment Records:
If requested by a member, what are they are allowed a copy of?
Their health record (HREC).
Closing Military Treatment Records:
Ensure the separation physical examination’s original document and copy is included where?
In the HREC prior to delivery to the supporting command.
What record needs to be with the closed health record?
The dental record.
The medical record is the property of what?
The U.S. Government.
The medical record is the property of the U.S. Government and must be maintained by who?
The MTF or DTF,
Which has primary cognizance over the care of the patient.
Onboard ships,
The Senior Medical Department Representative (SMDR)/ Senior Medical Officer (SMO),
Has the custodial responsibilities of medical records by authority delegated from who?
The Commanding Officer.
When hospitalized at a Naval Military Facility (MTF),
What should be included with the inpatient record?
The HREC or OREC.
Includes transfer by aeromedical evacuation
If admitted to MTF away from station, forward HREC upon request.
When hospitalized and transferred to Federal Facilities,
The HREC will accompany who?
The patient,
Or send as soon as possible.
When members are transferred to Veterans Administration Medical Centers (VAMC),
Forward a copy of what?
The HREC,
All medical boards,
IREC of a patient,
Transfer the original HREC to the cognizant MTF.
When hospitalized at civilian medical facilities,
Be sure to forward what?
HREC to activity having administrative cognizance,
After confirming that the member’s length of stay warrants the transfer.
When hospitalized in foreign nations
Be sure to do what?
Make entry of that fact in HREC,
Send HREC to MTF having administrative cognizance,
If applicable, place English translation of the narrative summary in the HREC.
Patients on UA in excess of 10 days,
Where do you send the record?
PSD,
Or
Unit holding member’s service/pay record.
When transferring a health record (HREC) to another duty station,
Be sure to verify what?
The HREC following MANMED Article 16-23(6),
Certify that the member has been processed for transfer.
Before transferring a medical record,
Be sure to include what?
The dental record.