CH 4 MEDICAL RECORDS Flashcards
Three major categories of primary medical records?
HREC
ORECs (including dental for retirees)
IRECs
Guidelines for record management are in what chapter of MANMED P-117?
16
To open a secondary record, write a note on what document in the primary treatment record?
DD Form 2766
Secondary records include?
Convenience
Temporary
Ancillary
Temporary record must contain what forms at a minimum?
Privacy Act Statement, DD 2005
Dental Health Questionnaire, NAVMED 6600/3
Dental Treatment Form, EZ603A
Medical record jacket?
NAVMED 6150/21-30
FMP 01-19
Children
FMP 30-39
mast-mob
Spouse
FMP 40-44
rice-rar
Mother/stepmother
FMP 45-49
rail-rabi
Father, Stepfather
FMP 50-54
lace-lord
Mother-in-law
FMP 55-59
lul-lab
Father-in-law
FMP 60-69
cheese-jab
Other authorized dependents
FMP 90-95
bus-bell
Beneficiary authorized by statute
FMP 98
Civilian Emergencies
FMP 99
All others
Imprint of privacy act statement is what form #
DD 2005
Health records are filed according to what system?
Terminal Digit Filing System (TDFS)
How is the social broken up in the TDFS?
12
34
567-89
TDFS is divided into how many sections?
100 (00-99)
Record jacket colors?
Old Guys Yell
Girls Talk
Boys Wander
And Parents Rest
0 = ORANGE 1 = GREEN 2 = YELLOW 3 = GREY 4 = TAN 5 = BLUE 6 = WHITE 7 = ALMOND 8 = PINK 9 = RED
PINK CARD (Charge out form)
NAVMED 6150/7
Part I
NAVMED 6150
Summary of care (always on top)
Part I
SF 601
Immunization record
Part I
NAVMED 6000/2
HIV testing
Part I
DD 771
Eyewear prescription
PART I
NAVMED 6490/1
(jar bus/gun)
Visual Record
Part I
NAVMED 6470/10
(jar case/fox)
Exposure to Ionizing Radiation
Exposure to Ionizing Radiation from Internally Deposited Radionuclide
Part I
NAVMED 6470/11
(Jar/Case/Ensign)
Part I
DD 2215
Reference Audiogram
Part 1
DD 2216
Hearing conservation data
Part 1
6224/1
(jan nerd/gun)
TB contact converter follow-up
Part 1
NAVMED 6260/5
(jan cheese/hive)
Asbestos medical surveillance program
Part I
DD 2493-1 (part i and ii)
(nerd bum)
Asbestos exposure - initial and periodic medical questionaire
Part 1
OPNAV 5100/15
(loot sos/tall)
Medical Surveillance Questionnaire
Part 2
NAVPERS 5510/1
(lul toes/gun)
Record Identifier for Personnel Reliability Program (PRP)
Part 2
SF 558
Medical Record - Emergency Care and Treatment record of Ambulance Care
Part 2
SF 513
Medical Record Consultation Sheet
Part 2
DD 2161
(net chat)
Referral for Civilian Medical Care
Part 2
Top sheet when patient is deceased
Attestation sheet
Part 2
DD 2064
Certification of Death
Part 2
SF 503
Autopsy Protocol
Part 2
SF 523
Authorization of autopsy
Part 2
SF 523A
Disposition of body
Part 2
SF 523B
Authorization for Tissue Donation
Inpatient Admission Disposition Record
NAVMED 6300/5
Narrative summary
SF 502
Abbreviated Medical Record
SF 539
Progress Notes
SF 509
Operation Report
SF 516
Anesthesia form?
SF 517
Request for Administration of Anesthesia
SF 522
Prenatal and Pregnancy Civilian Medical Care Notes
SF 233
Patient Evaluation Tag
DD 602
Part 3
NAVMED 1300/1
(Dam/SOS/gun)
Medical & Dental Overseas Screening
PART 3
NAVPERS 1300/16
(Dam SOS/dodge)
Report of Suitability for overseas assignment
Part 3
NAVMED 6100/1
(Chat,SOS/gun)
Med Board Report Cover Sheet
Part 3
NAVMED 6100/2
(Chat,SOS/glue)
Med Board Statement of Patient
Part 3
NAVMED 6100/3
(Chat,SOS/tree)
Med Board Certificate
Part 3
NAVMED 6100/5
(Chat,SOS/hive)
Abbreviated Temporary Limited Duty
Part 3
SF 2824C
(knife nerd)
Physician Statement for Employee Disability Retirement
Part 3
SF 47
Physical Fitness Inquiry for Motor Vehicle Operators
Part 3
SF 78
(cuff)
Certificate of Medical Examination
Part 3
NAVMED 6150/4
(Chat,lace/core)
Abstract of Service and Medical History
Part 3
NAVJAG 5800/10
Injury report
Part 3
NAVPERS 1754/1
(tac lord/cross)
Exceptional Family Member Program Application
Part 3
OPNAV 5211/9
(land tat/snow)
Record of Disclosure, Privacy Act 1974
Part 3
DD 877
Request for medical/dental records
Part 3
DD 2005
Privacy Act Statement
Part 4
SF 217
Epilepsy Medical Report
Part 4
SF 515
Tissue Examination
Part 4
SF 519A
Radiographic Report
Part 4
SF 519B
Radiologic Consultation Request/Report
Part 4
SF 519
Medical Record - Radiographic Reports
Part 4
SF 518
Blood or Blood Component Transfusion
Part 4
SF 520
EKG request
Part 4
SF 524
Radiation Therapy
Part 4
SF 525
Radiation Therapy Summary
Part 4
SF 53
Neurological Examination
Part 4
SF 531
Anatomical Figure
Part 4
SF 545
Lab Report Display
Part 4
SF 559
Alergen Extract Prescription new and refill
Part 4
SF 511
Vital signs record
Part 4
SF 512
Plotting Chart
Part 4
SF 512a
Blood pressure plotting chart
What should be done when duplicating part of a record?
Print “DUPLICATE” on the bottom of each form
Protocol for recording anthrax immunizations is outlined in what instruction?
SECNAVINST 6230.4