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
1
Q
What is the official name for a US Medical Outpatient and Dental Treatment Record?
A
NAVMED 6150/21-30
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).
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).
4
Q
Who ultimately has the responsibility for all medical records?
A
The Commanding Officer (CO)
5
Q
Are patients authorized to retain or maintain their original records?
A
No
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
7
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for SPONSORS?
A
20
8
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for CHILDREN?
A
01-19 (First Child = 01, Second = 02)
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)
10
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for MOTHERS/STEPMOTHERS?
A
40-44
11
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for FATHERS/STEPFATHERS?
A
45-49
12
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for MOTHER-IN-LAWS?
A
50-54
13
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for FATHER-IN-LAWS?
A
55-59
14
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for other authorized dependents?
A
60-69
15
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for beneficiary authorized by statute?
A
90-95
16
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for civilian emergencies?
A
98
17
Q
What Family Member Prefix (FMP) code is entered in the two diamonds for all others?
A
99
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
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
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
21
Q
What color is the record when the second to last SSN is 0?
A
Orange
22
Q
What color is the record when the second to last SSN is 1?
A
Green
23
Q
What color is the record when the second to last SSN is 2?
A
Yellow
24
What color is the record when the second to last SSN is 3?
Grey
25
What color is the record when the second to last SSN is 4?
Tan
26
What color is the record when the second to last SSN is 5?
Blue
27
What color is the record when the second to last SSN is 6?
White
28
What color is the record when the second to last SSN is 7?
Almond
29
What color is the record when the second to last SSN is 8?
Pink
30
What color is the record when the second to last SSN is 9?
Red
31
What form is the HealthRecord Receipt also known as the charge out form? (Part I)
NAVMED 6150/7
32
Summary of care form. (Part I)
NAVMED 6150
33
Immunization Record. (Part I)
SF 601
34
Chronological record of HIV Testing. (Part I)
NAVMED 6000/2
35
Eyewear Prescription. (Part I)
DD 771
36
Visual Record. (Part I)
NAVMED 6490/1
37
Record of Occupational Exposure to Ionizing Radiation. (Part I)
NAVMED 6470/10
38
Record of Exposure to Ionizing Radiation from Internally Deposited Radionuclide. (Part I)
NAVMED 6470/11
39
Reference Audiogram. (Part I)
DD 2215
40
Hearing Conservation Data. (Part I)
DD 2216
41
TB Contact converter follow up. (Part I)
NAVMED 6224/1
42
Asbestos Medical Surveillance Program. (Part I)
NAVMED 6260/5
43
Asbestos Exposure Questionnaire. (Part I)
DD 2493-1
44
Medical Surveillance Questionnaire. (Part I)
OPNAV 5100/15
45
Record Identifier for Personnel Reliability Program (PRP). (Part II)
NAVPERS 5510/1
46
Emergency Care and Treatment record of Ambulance Care. (Part II)
SF 558
47
Chronological Record of Medical Care. (Part II)
SF 600
48
Medical Record Consultation Sheet is used for outpatients who need to be referred to other healthcare providers or specialists. (Part II)
SF 513
49
Referral for Civilian Medical Care. (Part II)
DD 2161
50
Certification of Death. (Part II)
DD 2604
51
Autopsy Protocol. (Part II)
SF 503
52
Authorization for Autopsy. (Part II)
SF 523
53
Disposition of Body. (Part II)
SF 523A
54
Authorization for Tissue Donation. (Part II)
SF 523B
55
Inpatient Admission Disposition Record. (Part II)
NAVMED 6300/5
56
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)
SF 502
57
Abbreviated Medical Record. Used as a substitute for SF 502. (Part II)
SF 539
58
Progress Note. (Part II)
SF 509
59
Operation Report. (Part II)
SF 516
60
Anesthesia. (Part II)
SF 517
61
Request for Administration of Anesthesia. (Part II)
SF 522
62
Prenatal and Pregnancy Civilian Medical Care Notes. (Part II)
SF 233
63
Patient Evaluation Tag. (Part II)
DD 602
64
Medical and Dental Overseas Screening Review for Active Duty and Dependents. (Part III)
NAVMED 1300/1
65
Report of Suitability for Overseas Assignment. (Part III)
NAVPERS 1300/16
66
Medical Board Report Cover Sheet. (Part III)
NAVMED 6100/1
67
Medical Board Statement of Patient. (Part III)
NAVMED 6100/2
68
Medical Board Certificate. (Part III)
NAVMED 6100/3
69
Abbreviated Temporary Limited Duty. (Part III)
NAVMED 6100/5
70
Physician Statement for Employee Disability Retirement. (Part III)
SF 2824C
71
Physical Fitness Inquiry for Motor Vehicle Operators. (Part III)
SF 47
72
Certificate of Medical Examination. (Part III)
SF 78
73
Report of Medical History. (Part III)
DD 2807
74
Report of Medical Examination. (Part III)
DD 2808
75
Officer Physical Examination Special Questionnaire. (Part III)
NAVMED 6120/2
76
Annual Certificate Physical Condition. (Part III)
NAVMED 6120/3
77
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)
NAVMED 6150/4
78
Injury Report. (Part III)
NAVJAG 5800/10
79
Exceptional Family Member Program Application. (Part III)
NAVPERS 1754/1
80
Third Party collection Program. (Part III)
DD 2569
81
Record of Disclosure/Privacy Act 1974. (Part III)
OPNAV 5211/9
82
Request for Medical/Dental Records. (Part III)
DD 877
83
Epilepsy Medical Report. (Part IV)
SF 217
84
Tissue Examination. (Part IV)
SF 515
85
Radio graphic Report. (Part IV)
SF 519A
86
Radiologic Consultation Request/Report. (Part IV)
SF 519B
87
Medical Record-Radiographic Reports. (Part IV)
SF 519
88
Blood or Blood Component Transfusion. (Part IV)
SF 518
89
Electrocardiogram Request. (Part IV)
SF 520
90
Radiation Therapy. (Part IV)
SF 524
91
Radiation Therapy Summary. (Part IV)
SF 525
92
Interstitial/Inter-cavity Therapy. (Part IV)
SF 526
93
Group Muscle Strength, Join ROM, Girth and Length Measurements. (Part IV)
SF 527
94
Muscle Function by Nerve Distribution: Face, neck, and Upper Extremity. (Part IV)
SF 528
95
Muscle Function by Nerve Distribution: Trunk and Lower Extremity. (Part IV)
SF 529
96
Neurological Examination. (Part IV)
SF 530
97
Anatomical Figure. (Part IV)
SF 531
98
Gynecologic Cytology. (Part IV)
SF 541
99
Laboratory Report Display. (Part IV)
SF 545
100
Laboratory Reports. (Part IV)
SF 546-557
101
Allergen Extract Prescription New and Refill. (Part IV)
SF 559
102
Electroencephalogram Request and History. (Part IV)
SF 560
103
Vital Signs Record. (Part IV)
SF 511
104
Plotting Chart. (Part IV)
SF 512
105
Blood Pressure Plotting Chart. (Part IV)
SF 512A
106
When are records verified?
Report and Detach of Personnel, Physical Examination, and Annually
107
When a member is missing or MIA what must be done to close the members record?
Enter a summary of the relevant circumstances on an SF 600 with evidence
108
When a member becomes a deserter what must be done to close the members record?
Document the event fact on the SF 600, EZ603A and NAVMED 6150/4
109
When a member is being separated for disability what must be done to the members Health Record
The MTF will directly send a copy to the VA Regional Officer with a VA 526 (Claim of Benefits) to initiate the claim.
110
Can a copy of the record be carried to the VA by the member? Why?
No because it is considered a secondary evidence and it is not used to process a claim
111
What ink color must a provider type, print, or stamp the their name, grade or rating, and social security below their signature?
Black or blue ink
112
What is the minimum information that is documented in the identification block for patient care forms?
Patients FMP, sponsor's SSN, patient's name (last, first and MI), branch of service and patient' status.
113
What are the three methods currently being used to place patient identification on medical documents?
Embossed medical card, automated forms, and handwritten entries.
114
When a HREC or OREC is lost or destroyed, how will the custodian go about replacing the record?
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
When creating a duplicate record, what must the custodian do?
Designate "DUPLICATE RECORD" above the wording OUTPATIENT MEDICAL RECORD.
116
What must all the forms have if only part of the record is being duplicated?
"DUPLICATE" must be entered at the bottom of each form and enter event in an SF 600.
117
What is the process of microfiche?
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
How many years must loose forms be retained or kept?
1 year and anything after must be destroyed according to par. 6 of SECNAVINST 5212.5 = Navy and Marine Corps Records Disposition Manual
119
What is part 1 of the HREC/OREC?
Record of Preventative Medicine and Occupational Health
120
What is part 2 of the HREC/OREC?
Record of Medical Care and Treatment
121
What is part 3 of the HREC/OREC?
Physical Qualifications
122
What is part 4 of the HREC/OREC?
Record of Ancillary Studies, Inpatient Care, and miscellaneous forms
123
What is the form for Adult Prevention and Chronic Care Flowsheet?
DD 2766
124
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?
SF 600
125
What is the primary form for all outpatient care?
SF 600: Chronological Record of Medical Care
126
What form is used for routine inpatient admission, filed in the HREC and is the preferred form for imminent hospitalization?
SF 509: Medical Record-Progress Report
127
What form is the Dental Treatment form?
EZ603A
128
What form is the Dental Exam form?
EZ603
129
What form is a member's personal record of immunization?
PHS-731
130
What form is the record of occupational exposure to ionizing radiation?
DD Form 1141
131
What form is the Consultation Sheet?
SF 513
132
What is the form for Eyewear Perscription?
DD Form 771
133
What is the form for Dental Health Questionaire?
NAVMED 6600/3
134
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?
Part I
135
What part of the DREC files the Dental Health Questionnaire (NAVMED 6600/3)?
Part II
136
What is filed in the DREC's Part III?
Dental Exam Forms (EZ603)
137
What permits only the patients and their legal representatives to obtain information in the individuals medical record?
Privacy Act of 1974
138
Records are retained in the custody of whom?
Medical Officer or Dental Officer and SMDR with CO discretion.
139
Medical Records are subject to inspection by whom at anytime?
CO, superior CoC, the Fleet Medical Officer and other authorized inspectors.
140
When using the terminal digit filing system, how many equal sections are the central files divided into?
100
141
What are the primary, secondary and third number of the example SSN: 123-45-6789?
Primary Number=89, Secondary Number=67 and the Third Number=123-45
142
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?
The Surgeon General
143
Who is authorized in a Naval Treatment Facility to release information from records located within the command if proper credential are established?
Commanding Officers
144
What form is the Record of Disclosure Privacy Act 1974?
OPNAV Form 5211/9
145
What information may the Commanding Officer release to the public without the patient or the patient's Next of Kin (NOK)?
Patient's name; grade or rate; date of admission or disposition; age; sex; component, base, station, or organization; and general condition.
146
What must NOK or legal representatives present in order for the healthcare provider to release information?
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
What are the three instances that agencies may have a legitimate need for information within a Health Record?
To process government action, treat individual in the department's custody and release to federal or state courts or other administrative bodies.
148
Where should requests be sent for record retrieval for Navy and Marine Corps service members who were discharged before 31January1994? After 31January1994?
Before - National Personnel Records Center (NPRC)
| After - Veterans Affair (VA)
