CH4: Medical Records Flashcards
What is the official record jacket for Navy and Marine Corps personnel and DOD eligible?
U.S. Navy Medical Outpatient and Dental Treatment Record
What are the fundamentals of effective records’ management?
Opening, filing, verifying, and closing AD and reserve medical and dental records
Primary medical records are used for what documentation?
Outpatient and dental
Secondary medical records are used for what documentation?
Specialty
What are the 3 major categories of a primary medical record?
Health (HREC), Outpatient (OREC), Inpatient (IREC)
What is filed under the Health (HREC)?
Continuous care given to active duty, documents all outpatient care provided during a member’s career
Dental records file continuous care for?
AD, reserve, and their families
What is filed under the Outpatient (OREC)?
Ambulatory tx for someone other than AD (ie. retiree and family)
Where are summaries of inpatient (IREC) placed?
HREC (AD) or OREC (non-AD)
What secondary records will not be opened for AD?
Temporary and ancillary
Where are secondary records secured?
In a specialty clinic, separate from the primary record
What is included in a secondary record?
Convenience, temporary, ancillary
What does a convenience record contain?
Excerpts from the primary record
What is the purpose of the temporary record?
An original record, documenting a current course of tx
What must a temporary dental record contain?
Privacy Act Statement, DD 2005, Dental Health Questionnaire (NAVMED 6600/3), Dental Treatment Form (EZ603A)
When are health and dental records opened?
Becoming AD, retired and returned to AD, original lost/destroyed
Are records opened for mustangs?
No, they use their existing HREC
FMP for mother, stepmother?
40-44
FMP for father, stepfather
45-49
FMP for mother-in-law
50-54
FMP for father-in-law
55-59
FMP for Other Authorized Dependents
60-69
FMP for All Other
99
What information is in pencil on the inside front cover?
- Date of arrival
- PRD
- Address and number
- UIC and number
Where is Part II of the medical record located?
Front of center page
Where is the DD2005 Privacy Act Statement located?
In the front of the center page
Where is the Disclosure Accounting Record?
On the back of the center page
Where is the Forensic Examination form located?
Inside back cover
Define primary number.
Last two numbers in SSN
Define secondary number.
Second to last two numbers in SSN
Under the terminal digit filing system, central files are divided into how many equal sections?
100
What is the form number for orange?
NAVMED 6150/20
What is the form number for red?
NAVMED 6150/29
What is the form number for Health Record Receipt?
NAVMED 6150/7
What form is also known as the pink card?
Health Record Receipt, NAVMED 6150/7
What can be used in conjunction with the charge out form?
Charge out guide
What is a charge out guide?
A plastic folder with a pocket
What is the charge out guide in place of?
In place of the patient’s record until the record is returned
What is the DD form for Certificate of Death?
DD 2604
What is DD 2604?
Certificate of Death
What is the DD form for Narrative Summary?
SF 502
What is SF 502?
Narrative Summary
What is the DD form for Anesthesia?
SF 517
What is SF 517?
Anesthesia
What is the DD form for Request for Administration of Anesthesia?
SF 522
Where does the HM make an entry for an annual medical record verification?
SF 600
When is a record closed?
- Death or declared death
- Release from AD
- Transfer to the Fleet Reserve or release to inactive duty
Where do you record the closing entry?
NAVMED 6150/4, Abstract of Service and Medical History
Where do you document desertion?
SF 600, EZ603A and NAVMED 6150/4
How long do you retain loose forms?
1 year
What instructions states the policy for loose forms?
Paragraph six, SECNAVINST 5212.5 series Navy and Marine Corps Records Disposition Manual
What form is used for all outpatient care and where is it placed?
SF 600, in the HREC or OREC
What form is preferred for imminent hospitalization?
SF 509 Medical Record-Progress Report
What series is the Inpatient Data System?
BUMEDINST 6300.3
Where are entries regarding hypersensitivity documented?
SF 601 (IMM record), EZ603A (Dental Treatment Report), NAVMED 6150/10-19 (jackets), DD 2766 (Adult Preventive and Chronic Care Flow Sheet)
Where are international certificates of vaccination (PHS-731) kept?
Kept by the individual, personal record
Where are imms recorded in the PHS-731 transcribed?
DD 2766
What form is the consultation sheet?
SF 513
What is SF 513?
Consultation sheet
Define HQR.
Dental Health Questionnaire
What is the most current Dental Treatment Form?
EZ603A
Where are records retained?
In the custody of the MO or DO to which the member is assigned
What is the procedure is a member is hospitalized in a foreign nation?
Entry made in HREC, HREC retained on board and continued until the patient returns to duty.
