Chapter 4 Flashcards
Navy and Marine Corps personnel and DoD
eligible beneficiaries utilize the U.S. Navy
Medical Outpatient and Dental Treatment
Record (NAVMED 6150/21-30)
Guidelines for record management are in
Chapter 16 of the Manual of the Medical
Department (MANMED P-117).
The three major categories of primary medical records are: Health records (HRECs) Outpatient records (ORECs) o Dental records (DRECs) are part of HRECs (active duty) and ORECs (retirees and family members) Inpatient records (IRECs)
The primary medical records are used for
the documentation of outpatient medical and
dental care. A secondary medical record is
established by a patient’s specialty healthcare
provider and contains medical information
needed by that provider for a specific need.
Secondary medical records are maintained
separate from the primary medical record.
Opening a secondary medical record
requires the healthcare provider to write a note
on the DD Form 2766, Adult Preventive and
Chronic Care Flow Shee
Secondary medical records include:
Convenience records
Temporary records
Ancillary records
The temporary dental record must, at a minimum contain the following forms: Privacy Act Statement, DD 2005 Dental Health Questionnaire, NAVMED 6600/3 Dental Treatment Form, EZ603A
For members who do not have an
SSN (e.g., foreign military personnel) use
NAVMED 6150/29 as the treatment record
A “substitute” SSN should be created for
these members by assigning the numbers “9999”
as the last four digits of the SSN and assigning
the first five digits in number sequence (e.g.,
first SSN 000-01-9999, the second SSN
000-02-9999).
Identify flag officers and general officers by
stamping or printing “FLAG OFFICER” or
“GENERAL OFFICER,” as appropriate, on the
lower portion of the patient identification box. If
a patient identification label is used, print or
stamp the appropriate identification below the
label.
NAVMED 6000/2, Chronological record of HIV Testing NAVMED 6224/1, TB Contact converter followup SF 502, Narrative Summary
All records are verified annually by medical
and dental personnel having custody of them.
Health records will be reviewed when service
members report and detach from their
commands, and at the time of any physical
examinations.
Each record will be carefully reviewed and
any errors or discrepancies corrected. Items to
be reviewed during any verification include:
form placement, order of forms (chronological),
and completeness and accuracy of patient
identification data on the record jacket and on
each piece of medical documentation. In
addition, verify that the Privacy Act Statement
has been signed, the DD 2766 (covered later in
this chapter) is updated as necessary, operational
and occupational requirements updated, and
currency of immunizations and accuracy of
allergy documentation are complete.
Upon completion of an annual medical
record verification, the HM will make an entry
on the SF 600 for medical records and black-out
the corresponding year block on the front leaf of
the jacket with a black felt-tip pen. With this
procedure, records that have not been verified
during the calendar year can be identified and
the annual verification accomplished. The
annual verification section is located on the
right-hand side of the front cover of the record
jacket as a series of blocks numbered with the
years 1996 thru 2014. The year of verification
will be blackened out for health records once it
has been verified.
DD 877, Request for Medical/Dental
Records
For dental records, document verification on
the EZ603A and as they are verified at the time
of the annual exam there is no requirement to
blacken the verification year. The information
on the inside of the jacket front cover should be
updated in pencil only for both records. This
information will be entered at the time of record
check-in (receipt) and will be kept current at all
times by erasing previous, outdated entries.
Allow active duty members to hand carry
their records, unless the facility or member’s
command determines it is not in the Navy’s
or member’s interest to do so. If the medical
and dental records are not to be hand
carried, forward them via certified mail
along with a DD Form 877, Request for
Medical/Dental Records Information, or
place medical and dental records in the
custody of authorized personnel.
When recording positive results (10 mm or
more induration) of the tuberculin skin test
(TST), refer to BUMEDINST 6224.8 series
Tuberculosis Control Program, f
SF 515, Tissue Examination
NAVMED 6150, Summary of care form (always top form)
NAVMED 6000/2, Chronological record of HIV Testing
DD 2215, Reference Audiogram
DD 2216, Hearing Conversation Data
NAVMED 6224/1, TB Contact converter followup
SF 513, Medical Record Consultation Sheet
SF 502, Narrative Summary
SF 509, Progress Notes
DD 2604, Certificate of Death
NAVPERS 1300/16, Report of Suitability for Overseas Assignment
NAVMED 1300/1, Medical and Dental Overseas Screening Review for Active Duty and Dependents
DD 2005, Privacy Act Statement
DD 877, Request for Medical/Dental Records
NAVPERS 1754/1, Exceptional Family Member Program Application
SF 545, Laboratory Report Display
What information is located in the Medical Record’s Part I (Inside Front Cover)?
Pencil entries that include
- Date of arrival
- Projected rotation date
- Home address and telephone number
- Command UIC and telephone number
What information is located in the Medical Record’s Part II (Front of Center Page)?
IMPRINT OF DD 2005, PRIVACY ACT STATEMENT
What information is located in the Medical Record’s Part III (Back of Center Page)?
DISCLOSURE ACCOUNTING RECORD.
