chapter 4: Medical reacords Flashcards
What is the offical record jacket for the chronological documentation of medical and dental care?
NAVMED 6150/21-30 U.S Navy Medical Outpatient and Dental Treatment Record
MANMED P-117
Manual of the Medical Department
What is the primary medical record?
Used for the documentation of outpatient medical and dental care.
What is the secondary medical record?
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.
What are the three major categories of primary medical records?
Health records (HRECs), Outpatient records(ORECs), and Inpatient records (IRECs)
What does the health record contain?
a file of continuous care given to active duty members and documents all outpatient care provided during a member’s career.
What does the dental record contain
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.
What does the outpaitent record contain?
a file of continuous care that documents ambulatory treatment recieved by a person other than an active duty person.
What does the inpatient record contain?
a medical file that documents care provided to a patient assigned to a designated inpatient bed at an MTF or ship.
What is required when opening a secondary medical record?
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.
What do secondary medical records include?
Convenience records, temporary records, ancillary records
What must the temporary dental records contain?
Privacy Act Statement, DD 2005; Dental Health Questionnaire, NAVMED 6600/3; and Dental Treatment Form EZ 603A
Who has overall responsibilities of all medical records
the CO
who is not authorized to retain or maintain the original HREC, OREC, or dental record?
the patient
Who opens HRECs for civilian applicants who are accepted for an officer appointment?
Recuriting commands
DD2807
Report of Medical History
DD2808
Report of medical examination
Who is the HREC custodian for inactive reserve personnel and is responsible for records’ preparation and maintenance?
The Naval Reserve Personnel Center (NRPC), New Orleans
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.
NAVMED 6150/21-30
What type of pen is used to record all identifying data, except in the “Pencil Entries” block?
a felt tip or permanent black ink pen
FMP for sponsor
20
FMP for children
01-19
FMP for spouse
30
FMP for mother or stepmother
40-44
