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NAVEDTRA 14295B: HM Manual > Chapter 4 - Medical Records > Flashcards

Chapter 4 - Medical Records Flashcards

0
Q

Where can HMs find guidance for record management?

A

MANMED P-117 (Manual of the Medical Department) Chapter 16

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1
Q

What is the official name for a US Medical Outpatient and Dental Treatment Record?

A

NAVMED 6150/21-30

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2
Q

What are the three major categories of primary records that are used for the documentation of outpatient medical and dental care?

A

Health records (HRECs = Active Duty), Outpatient records (ORECs = retires and family members), and Inpatient records (IRECs = MTF).

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3
Q

What type of record is established by a patient’s specialty healthcare provider and contains medical information needed by that provider for a specific need? (OBGYN, Psychiatry, Psychology clinic)

A

Secondary medical record (Convenience, Temporary and Ancillary Records).

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4
Q

Who ultimately has the responsibility for all medical records?

A

The Commanding Officer (CO)

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5
Q

Are patients authorized to retain or maintain their original records?

A

No

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6
Q

Where is the pencil entry located on the outer front cover of the medical records? What must be included on the entry?

A
  • Upper left corner

- Includes command and rank

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7
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for SPONSORS?

A

20

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8
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for CHILDREN?

A

01-19 (First Child = 01, Second = 02)

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9
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for SPOUSES?

A

30-39 (First Spouse = 30, Second Spouse = 31)

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10
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for MOTHERS/STEPMOTHERS?

A

40-44

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11
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for FATHERS/STEPFATHERS?

A

45-49

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12
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for MOTHER-IN-LAWS?

A

50-54

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13
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for FATHER-IN-LAWS?

A

55-59

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14
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for other authorized dependents?

A

60-69

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15
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for beneficiary authorized by statute?

A

90-95

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16
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for civilian emergencies?

A

98

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17
Q

What Family Member Prefix (FMP) code is entered in the two diamonds for all others?

A

99

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18
Q

How do records indicate the the member is active duty?

A

1/2-inch red cellophane tape to the record category block on the right edge of the inside back cover

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19
Q

The following entries inside the front cover the record are written in what: Date of arrival, PRD, home address, telephone #, UIC and work telephone #?

A

Pencil

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20
Q

The privacy act statement in the front of the center page of a record is what form? What must the entry be in and by who?

A
  • DD 2005
  • Black pen
  • Patient, parent or guardian
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21
Q

What color is the record when the second to last SSN is 0?

A

Orange

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22
Q

What color is the record when the second to last SSN is 1?

A

Green

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23
Q

What color is the record when the second to last SSN is 2?

A

Yellow

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24
Q

What color is the record when the second to last SSN is 3?

A

Grey

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25
Q

What color is the record when the second to last SSN is 4?

A

Tan

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26
Q

What color is the record when the second to last SSN is 5?

A

Blue

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27
Q

What color is the record when the second to last SSN is 6?

A

White

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28
Q

What color is the record when the second to last SSN is 7?

A

Almond

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29
Q

What color is the record when the second to last SSN is 8?

A

Pink

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30
Q

What color is the record when the second to last SSN is 9?

A

Red

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31
Q

What form is the HealthRecord Receipt also known as the charge out form? (Part I)

A

NAVMED 6150/7

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32
Q

Summary of care form. (Part I)

A

NAVMED 6150

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33
Q

Immunization Record. (Part I)

A

SF 601

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34
Q

Chronological record of HIV Testing. (Part I)

A

NAVMED 6000/2

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35
Q

Eyewear Prescription. (Part I)

A

DD 771

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36
Q

Visual Record. (Part I)

A

NAVMED 6490/1

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37
Q

Record of Occupational Exposure to Ionizing Radiation. (Part I)

A

NAVMED 6470/10

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38
Q

Record of Exposure to Ionizing Radiation from Internally Deposited Radionuclide. (Part I)

A

NAVMED 6470/11

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39
Q

Reference Audiogram. (Part I)

A

DD 2215

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40
Q

Hearing Conservation Data. (Part I)

A

DD 2216

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41
Q

TB Contact converter follow up. (Part I)

A

NAVMED 6224/1

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42
Q

Asbestos Medical Surveillance Program. (Part I)

A

NAVMED 6260/5

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43
Q

Asbestos Exposure Questionnaire. (Part I)

A

DD 2493-1

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44
Q

Medical Surveillance Questionnaire. (Part I)

A

OPNAV 5100/15

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45
Q

Record Identifier for Personnel Reliability Program (PRP). (Part II)

A

NAVPERS 5510/1

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46
Q

Emergency Care and Treatment record of Ambulance Care. (Part II)

A

SF 558

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47
Q

Chronological Record of Medical Care. (Part II)

A

SF 600

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48
Q

Medical Record Consultation Sheet is used for outpatients who need to be referred to other healthcare providers or specialists. (Part II)

A

SF 513

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49
Q

Referral for Civilian Medical Care. (Part II)

A

DD 2161

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50
Q

Certification of Death. (Part II)

A

DD 2604

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51
Q

Autopsy Protocol. (Part II)

A

SF 503

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52
Q

Authorization for Autopsy. (Part II)

A

SF 523

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53
Q

Disposition of Body. (Part II)

A

SF 523A

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54
Q

Authorization for Tissue Donation. (Part II)

A

SF 523B

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55
Q

Inpatient Admission Disposition Record. (Part II)

A

NAVMED 6300/5

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56
Q

Narrative Summary is used to summarize clinical data relative to treatment received during periods of hospitalizations. SF 539 may be used as a substitute. (Part II)

A

SF 502

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57
Q

Abbreviated Medical Record. Used as a substitute for SF 502. (Part II)

A

SF 539

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58
Q

Progress Note. (Part II)

A

SF 509

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59
Q

Operation Report. (Part II)

A

SF 516

60
Q

Anesthesia. (Part II)

A

SF 517

61
Q

Request for Administration of Anesthesia. (Part II)

A

SF 522

62
Q

Prenatal and Pregnancy Civilian Medical Care Notes. (Part II)

A

SF 233

63
Q

Patient Evaluation Tag. (Part II)

A

DD 602

64
Q

Medical and Dental Overseas Screening Review for Active Duty and Dependents. (Part III)

A

NAVMED 1300/1

65
Q

Report of Suitability for Overseas Assignment. (Part III)

A

NAVPERS 1300/16

66
Q

Medical Board Report Cover Sheet. (Part III)

A

NAVMED 6100/1

67
Q

Medical Board Statement of Patient. (Part III)

A

NAVMED 6100/2

68
Q

Medical Board Certificate. (Part III)

A

NAVMED 6100/3

69
Q

Abbreviated Temporary Limited Duty. (Part III)

A

NAVMED 6100/5

70
Q

Physician Statement for Employee Disability Retirement. (Part III)

A

SF 2824C

71
Q

Physical Fitness Inquiry for Motor Vehicle Operators. (Part III)

A

SF 47

72
Q

Certificate of Medical Examination. (Part III)

A

SF 78

73
Q

Report of Medical History. (Part III)

A

DD 2807

74
Q

Report of Medical Examination. (Part III)

A

DD 2808

75
Q

Officer Physical Examination Special Questionnaire. (Part III)

A

NAVMED 6120/2

76
Q

Annual Certificate Physical Condition. (Part III)

A

NAVMED 6120/3

77
Q

Abstract of Service and Medical History provides a chronological history of the duty stations to which a member has been assigned for duty and treatment. (Part III)

A

NAVMED 6150/4

78
Q

Injury Report. (Part III)

A

NAVJAG 5800/10

79
Q

Exceptional Family Member Program Application. (Part III)

A

NAVPERS 1754/1

80
Q

Third Party collection Program. (Part III)

A

DD 2569

81
Q

Record of Disclosure/Privacy Act 1974. (Part III)

A

OPNAV 5211/9

82
Q

Request for Medical/Dental Records. (Part III)

A

DD 877

83
Q

Epilepsy Medical Report. (Part IV)

A

SF 217

84
Q

Tissue Examination. (Part IV)

A

SF 515

85
Q

Radio graphic Report. (Part IV)

A

SF 519A

86
Q

Radiologic Consultation Request/Report. (Part IV)

A

SF 519B

87
Q

Medical Record-Radiographic Reports. (Part IV)

A

SF 519

88
Q

Blood or Blood Component Transfusion. (Part IV)

A

SF 518

89
Q

Electrocardiogram Request. (Part IV)

A

SF 520

90
Q

Radiation Therapy. (Part IV)

A

SF 524

91
Q

Radiation Therapy Summary. (Part IV)

A

SF 525

92
Q

Interstitial/Inter-cavity Therapy. (Part IV)

A

SF 526

93
Q

Group Muscle Strength, Join ROM, Girth and Length Measurements. (Part IV)

A

SF 527

94
Q

Muscle Function by Nerve Distribution: Face, neck, and Upper Extremity. (Part IV)

A

SF 528

95
Q

Muscle Function by Nerve Distribution: Trunk and Lower Extremity. (Part IV)

A

SF 529

96
Q

Neurological Examination. (Part IV)

A

SF 530

97
Q

Anatomical Figure. (Part IV)

A

SF 531

98
Q

Gynecologic Cytology. (Part IV)

A

SF 541

99
Q

Laboratory Report Display. (Part IV)

A

SF 545

100
Q

Laboratory Reports. (Part IV)

A

SF 546-557

101
Q

Allergen Extract Prescription New and Refill. (Part IV)

A

SF 559

102
Q

Electroencephalogram Request and History. (Part IV)

A

SF 560

103
Q

Vital Signs Record. (Part IV)

A

SF 511

104
Q

Plotting Chart. (Part IV)

A

SF 512

105
Q

Blood Pressure Plotting Chart. (Part IV)

A

SF 512A

106
Q

When are records verified?

A

Report and Detach of Personnel, Physical Examination, and Annually

107
Q

When a member is missing or MIA what must be done to close the members record?

A

Enter a summary of the relevant circumstances on an SF 600 with evidence

108
Q

When a member becomes a deserter what must be done to close the members record?

A

Document the event fact on the SF 600, EZ603A and NAVMED 6150/4

109
Q

When a member is being separated for disability what must be done to the members Health Record

A

The MTF will directly send a copy to the VA Regional Officer with a VA 526 (Claim of Benefits) to initiate the claim.

110
Q

Can a copy of the record be carried to the VA by the member? Why?

A

No because it is considered a secondary evidence and it is not used to process a claim

111
Q

What ink color must a provider type, print, or stamp the their name, grade or rating, and social security below their signature?

A

Black or blue ink

112
Q

What is the minimum information that is documented in the identification block for patient care forms?

A

Patients FMP, sponsor’s SSN, patient’s name (last, first and MI), branch of service and patient’ status.

113
Q

What are the three methods currently being used to place patient identification on medical documents?

A

Embossed medical card, automated forms, and handwritten entries.

114
Q

When a HREC or OREC is lost or destroyed, how will the custodian go about replacing the record?

A

Designate “REPLACEMENT” in front of the jacket and enter event on an SF 600 that should be filed. If old record is discovered, place all entries in replacement record in the original record.

115
Q

When creating a duplicate record, what must the custodian do?

A

Designate “DUPLICATE RECORD” above the wording OUTPATIENT MEDICAL RECORD.

116
Q

What must all the forms have if only part of the record is being duplicated?

A

“DUPLICATE” must be entered at the bottom of each form and enter event in an SF 600.

117
Q

What is the process of microfiche?

A

All forms are replaced for protection and preservation and make the envelope a permanent part of the record.

The front of the envelope must include: member’s full name, FMP, SSN, DOB, and list the original forms contained in the envelope.

118
Q

How many years must loose forms be retained or kept?

A

1 year and anything after must be destroyed according to par. 6 of SECNAVINST 5212.5 = Navy and Marine Corps Records Disposition Manual

119
Q

What is part 1 of the HREC/OREC?

A

Record of Preventative Medicine and Occupational Health

120
Q

What is part 2 of the HREC/OREC?

A

Record of Medical Care and Treatment

121
Q

What is part 3 of the HREC/OREC?

A

Physical Qualifications

122
Q

What is part 4 of the HREC/OREC?

A

Record of Ancillary Studies, Inpatient Care, and miscellaneous forms

123
Q

What is the form for Adult Prevention and Chronic Care Flowsheet?

A

DD 2766

124
Q

The following entries should be documented on what form: Imminent Hospitalization, special procedures and therapy, sick call visits, injuries or poisonings, line-of-duty inquiries, binnacle list and sick list, and reservist check-in and check-out statements?

A

SF 600

125
Q

What is the primary form for all outpatient care?

A

SF 600: Chronological Record of Medical Care

126
Q

What form is used for routine inpatient admission, filed in the HREC and is the preferred form for imminent hospitalization?

A

SF 509: Medical Record-Progress Report

127
Q

What form is the Dental Treatment form?

A

EZ603A

128
Q

What form is the Dental Exam form?

A

EZ603

129
Q

What form is a member’s personal record of immunization?

A

PHS-731

130
Q

What form is the record of occupational exposure to ionizing radiation?

A

DD Form 1141

131
Q

What form is the Consultation Sheet?

A

SF 513

132
Q

What is the form for Eyewear Perscription?

A

DD Form 771

133
Q

What is the form for Dental Health Questionaire?

A

NAVMED 6600/3

134
Q

What part of the DREC’s (NAVMED 6150/21) file the following: un-mounted radiographs in envelopes, sequential bite wing radiograph, and planographic or full mouth radiograph?

A

Part I

135
Q

What part of the DREC files the Dental Health Questionnaire (NAVMED 6600/3)?

A

Part II

136
Q

What is filed in the DREC’s Part III?

A

Dental Exam Forms (EZ603)

137
Q

What permits only the patients and their legal representatives to obtain information in the individuals medical record?

A

Privacy Act of 1974

138
Q

Records are retained in the custody of whom?

A

Medical Officer or Dental Officer and SMDR with CO discretion.

139
Q

Medical Records are subject to inspection by whom at anytime?

A

CO, superior CoC, the Fleet Medical Officer and other authorized inspectors.

140
Q

When using the terminal digit filing system, how many equal sections are the central files divided into?

A

100

141
Q

What are the primary, secondary and third number of the example SSN: 123-45-6789?

A

Primary Number=89, Secondary Number=67 and the Third Number=123-45

142
Q

Who is officially responsible for administering and supervising the execution of SECNAVINST 5211.5 Series (Department of the Navy Privacy Act Program (PAP)), as it pertains to the Health Care Treatment Record System?

A

The Surgeon General

143
Q

Who is authorized in a Naval Treatment Facility to release information from records located within the command if proper credential are established?

A

Commanding Officers

144
Q

What form is the Record of Disclosure Privacy Act 1974?

A

OPNAV Form 5211/9

145
Q

What information may the Commanding Officer release to the public without the patient or the patient’s Next of Kin (NOK)?

A

Patient’s name; grade or rate; date of admission or disposition; age; sex; component, base, station, or organization; and general condition.

146
Q

What must NOK or legal representatives present in order for the healthcare provider to release information?

A

Certified copy of a court order and proof that the member has been declared mentally incompetent or insane, or furnish adequate proof of death.

147
Q

What are the three instances that agencies may have a legitimate need for information within a Health Record?

A

To process government action, treat individual in the department’s custody and release to federal or state courts or other administrative bodies.

148
Q

Where should requests be sent for record retrieval for Navy and Marine Corps service members who were discharged before 31January1994? After 31January1994?

A

Before - National Personnel Records Center (NPRC)

After - Veterans Affair (VA)

NAVEDTRA 14295B: HM Manual (25 decks)

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