chapter 4: Medical reacords

Question 1

What is the offical record jacket for the chronological documentation of medical and dental care?

Answer 1

NAVMED 6150/21-30 U.S Navy Medical Outpatient and Dental Treatment Record

Question 2

MANMED P-117

Answer 2

Manual of the Medical Department

Question 3

What is the primary medical record?

Answer 3

Used for the documentation of outpatient medical and dental care.

Question 4

What is the secondary medical record?

Answer 4

is established by a patient’s specialty healthcare provider and containsmedical information needed by that provider for a specific need. They are maintained separate from the primary medical record.

Question 5

What are the three major categories of primary medical records?

Answer 5

Health records (HRECs), Outpatient records(ORECs), and Inpatient records (IRECs)

Question 6

What does the health record contain?

Answer 6

a file of continuous care given to active duty members and documents all outpatient care provided during a member’s career.

Question 7

What does the dental record contain

Answer 7

A file of continuous care given to active duty and reserve members and their familes. it contains all documents of dental care provided during a member’s career.

Question 8

What does the outpaitent record contain?

Answer 8

a file of continuous care that documents ambulatory treatment recieved by a person other than an active duty person.

Question 9

What does the inpatient record contain?

Answer 9

a medical file that documents care provided to a patient assigned to a designated inpatient bed at an MTF or ship.

Question 10

What is required when opening a secondary medical record?

Answer 10

requires the health care provider to write a not on the DD Form 2766, Adult Preventive and Chronic Care Flow Sheet in the primary treatment record.

Question 11

What do secondary medical records include?

Answer 11

Convenience records, temporary records, ancillary records

Question 12

What must the temporary dental records contain?

Answer 12

Privacy Act Statement, DD 2005; Dental Health Questionnaire, NAVMED 6600/3; and Dental Treatment Form EZ 603A

Question 13

Who has overall responsibilities of all medical records

Answer 13

the CO

Question 14

who is not authorized to retain or maintain the original HREC, OREC, or dental record?

Answer 14

the patient

Question 15

Who opens HRECs for civilian applicants who are accepted for an officer appointment?

Answer 15

Recuriting commands

Question 16

DD2807

Answer 16

Report of Medical History

Question 17

DD2808

Answer 17

Report of medical examination

Question 18

Who is the HREC custodian for inactive reserve personnel and is responsible for records’ preparation and maintenance?

Answer 18

The Naval Reserve Personnel Center (NRPC), New Orleans

Question 19

What will be prepared when a record is open or when the existing jacket has been damaged or is deteriorating to the point of illegibility.

Answer 19

NAVMED 6150/21-30

Question 20

What type of pen is used to record all identifying data, except in the “Pencil Entries” block?

Answer 20

a felt tip or permanent black ink pen

Question 21

FMP for sponsor

Answer 21

20

Question 22

FMP for children

Answer 22

01-19

Question 23

FMP for spouse

Answer 23

30

Question 24

FMP for mother or stepmother

Answer 24

40-44

Question 25

FMP for father or stepfather

Answer 25

45-49

Question 26

FMP for mother-in-law

Answer 26

50-54

Question 27

FMP for father-in-law

Answer 27

55-59

Question 28

FMP for all other authorized dependents

Answer 28

60-69

Question 29

FMP for beneficiary authorized by statute

Answer 29

90-95

Question 30

FMP for civilian Emergencies

Answer 30

98

Question 31

FMP for all others

Answer 31

99

Question 32

What abbreviation will be used if the member has no middle name

Answer 32

NMN

Question 33

What on the record indicates that it is an active duty record?

Answer 33

1/2 in red cellophane tape to the record category

Question 34

How to you prepare part one of the medical record?(inside front cover)

Answer 34

date of arrival, projected rotation date, home address and telephone number, command uic and telephone number

Question 35

How do you prepare part two of the medical record? (fron of center page)

Answer 35

Imprint of DD2005, Privacy Act Statement must be signed and dated

Question 36

How do you prepare part three of the medical record?(back of center page

Answer 36

Disclosure Accounting record will be filled out as needed