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BMTCP > BN3 Records > Flashcards

BN3 Records Flashcards

1
Q

What term means arranged according to the order of time?

A

chronological

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2
Q

What is a continuous file of dental care and treatment given to active duty and reserve members and their families?

A

Dental Record

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3
Q

What term describes a number that designates sponsorship?

A

Family Member Prefix (FMP)

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4
Q

What term describes a file of continuous care given to an active duty member and documents all outpatient care provided during a member’s career?

A

Health Record (HREC)

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5
Q

What term describes a medical file which documents care provided to a patient assigned to a designated inpatient bed in a medical treatment facility (MTF) or ship?

A

Inpatient Health Record (IREC)

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6
Q

What term describes a file of continuous care which documents ambulatory received by a person other than an active duty member?

A

Outpatient Record (OREC)

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7
Q

what color record would a “0” be?

A

orange

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8
Q

what color record would “1” be?

A

Green

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9
Q

what color record would “2” be?

A

yellow

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10
Q

what color record would “3” be?

A

Gray

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11
Q

what color record would “4” be?

A

tan/mustard

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12
Q

what color record would “5” be?

A

blue

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13
Q

what color record would “6” be?

A

white

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14
Q

what color record would “7” be?

A

brown

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15
Q

what color record would “8” be?

A

pink

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16
Q

what color record would “9” be?

A

red

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17
Q

what is the family member prefix for sponsor?

A

20

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18
Q

what is the family member prefix for spouse?

A

30

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19
Q

what is the family member prefix for second spouse?

A

31

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20
Q

what is the family member prefix for second child?

A

02

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21
Q

what is the family member prefix for first child?

A

01

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22
Q

what is the family member prefix for foreign military?

A

99

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23
Q

What are the four parts of the health record

A

Part 1: Record of preventive medicine and occupational health. Part 2: Chronological record of medical care and treatment. Part 3: Physical qualifications, physical profiles and exposures forms. Part 4: Record of Ancillary Studies and miscellaneous forms

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24
Q

What forms contain a record of prophylactic immunizations and contains information concerning hypersensitivities and allergies?

A

SF601/ DD2766C

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25
Q

What form is the chronological record of HIV testing?

A

NAVMED 6000/2

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26
Q

What form is the baseline audiogram?

A

DD2215

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27
Q

What form would you find a record of a member’s medical history (e.g sickcall) that is filed in chronological order with the most recent on top?

A

SF600

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28
Q

What form would you find a record of care given in an emergency situation? This form is interfiled with the SF600s

A

SF558

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29
Q

What form would be used to summarize clinical data relative to treatment received during periods of hospitalization?

A

SF 502

30
Q

What from is a medical record continuation?

A

SF 507

31
Q

What from is a progress note?

A

SF 509

32
Q

What form is used to refer a patient to a specialist for detailed exam and/or procedure?

A

SF513

33
Q

What form is used to document and inform members of their privacy rights?

A

DD Form 2005

34
Q

Where are SF 513s filed?

A

immediately above the SF 600 or SF 558 containing the last entry prior to date of SF513

35
Q

What form is a Line of Duty Determination?

A

AF Form 348

36
Q

What form is a record of Inpatient treatment?

A

AF 565

37
Q

What AF form is the summary of care?

A

AF1480

38
Q

What form is the Abstract of Service and Medical Hx?

A

NAVMED 6150/4

39
Q

What form is the third Party Collection Party form?

A

DD 2569

40
Q

What form is the Record of Disclosure?

A

OPNAV 5211/9

41
Q

What form is the request for medical/dental record information?

A

DD 877

42
Q

When is the DD877 used?

A

to request medical/dental records.

Used when permanently transferring medial and dental records to another facility

43
Q

What form is the pre-deployment health assessment?

A

DD2795

44
Q

What form is the post deployment health assessment?

A

DD2796

45
Q

What form is the Post deployment health re-assessment?

A

DD2900

46
Q

What form is the report of Medical Examination?

A

DD2808 or SF88

47
Q

What form is the Report of Medical History?

A

DD2807 or SF93

48
Q

what AF form is the Physical Profile Serial Report?

A

AF form 422

49
Q

What form is the Laboratory Report Display?

A

SF 545

50
Q

What form is the Radiologic consultation requests/reports?

A

SF 519

51
Q

What form is lab results?

A

SF 602

52
Q

What does part 1 of the dental record contain?

A

x-rays

53
Q

What form is the dental health questionnaire?

A

NAVMED 6600/3

54
Q

Where in the dental records is the NAVMED 6600/3(dental health questionnaire) located?

A

Part 2

55
Q

What form is used for most dental exams and is not used for emergencies?

A

EZ 603

56
Q

Where is the EZ603 located in the dental record?

A

part 3

57
Q

What form documents the most current dental treatment and what section is it located in?

A

EZ603A in Part 4

58
Q

How are EZ603As and SF603s filed?

A

Reverse chronological order

59
Q

What Inpatient form provides a summary of patient’s health history to identify actual and potential nursing care problems?

A

NAVMED 6550/14(Patient data base)

60
Q

What inpatient form provides a summary of inpatient data and treatment received during hospitalization?

A

SF 502 (Narrative Summary)

61
Q

What inpatient form is used to record a course of current hospitalization, including signs and symptoms, duration of complaints and the circumstances of admission?

A

SF504 (history part 1)

62
Q

What inpatient form records occupation, military history, lifetime injuries and illnesses, as well as drug sensitivities and allergies?

A

SF505 (History Part 2&3)

63
Q

What inpatient form is a record of physical examinations, including the patient’s physical and mental characteristics?

A

SF506 (Physical Exam)

64
Q

What inpatient form provides written instructions by the physician, directing the medical care and treatment of the patient?

A

SF 508(Doctor’s orders)

65
Q

What inpatient form is used by physicians to record a patient’s response to treatment?

A

SF509 (Progress note)

*Other medical personnel may use this form to record comments (dietitian, anesthetist)

66
Q

What inpatient form is used for observations, patients progress, treatments and some medications are recorded by the nurses and corpsman/technicians?

A

SF510 (Nursing Notes)

67
Q

What inpatient form is used to standardize treatment and provide a ready reference for care given to a patient?

A

NAVMED 6550/12 (Patient Profile) or Air Force Inpatient Flowchart

68
Q

What inpatient form is a record of temperature, pulse, blood pressure, respirations, height and weight as well as intake and output?

A

SF 511 (Vital Signs Record)

69
Q

What inpatient form is used to record all medications administered during a seven day time period?

A

NAVMED 6550/8 Medication Administration record

70
Q

What form is used to accurately document a patient’s actual fluid intake and output (I&O) over a twenty-four hour period?

A

DD 792 (Twenty-Four Hour Intake and Output worksheet)

71
Q

Who is ultimately responsible for the maintenance and storage of Health Records?

A

The commanding officer of the treatment facility

BMTCP (30 decks)

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