HM Chapter 04: Medical Records Flashcards
What are the medical records named?
NAVMED 6150/20-29
How many category of records are there?
3: health, outpatient, inpatient
Temporary records are also known as
Ancillary records
Who has ultimate responsibility for medical records?
Commanding Officer
Pencil entries are made….
In the first section of medical record in upper left corner; includes command & rank
01-19 is
Dependent Child
12 is …
Activated reserve
20-29 is …
Active Duty
30-39 is
Dependent spouse/former spouse
40-44 is …
Dependent Mother or Stepmother
45-49 is …
Dependent father or stepfather
50-54 is …
Dependent mother in law
55-59 is …
Dependent father in law
60-69 is …
Other authorized dependents
98 is …
Civilian employees
99 is …
All others
Preparing the medical record includes 3 parts, which are…
Part 1: done in pencil
Part 2: Signed DD 2005 (privacy act) in pen
Part 3: Disclosure Accounting Record
What’s the name if the navy’s medical record filing system?
Terminal Digit Filing System
NAVMED 6150/20
Orange
NAVMED 6150/21
Green
NAVMED 6150/22
Yellow
NAVMED 6150/23
Gray
NAVMED 6150/24
Tan
NAVMED 6150/25
Blue
NAVMED 6150/26
White
NAVMED 6150/27
Almond
NAVMED 6150/28
Pink
NAVMED 6159/29
Pink
NAVMED 6150/7
Health Record Receipt (pink card)
What to do for foreign medical records?
Enter 00; also NMN is notated on front cover to indicate no middle name.
Located in part 1 of medical record?
Record of Preventive & Occupational Health
Located in part 2 of medical record
Record of medical care & treatment
Located in Part 3 of medical record
Physical qualifications
Located in part 4 of medical records
Record of ancillary studies, inpatient care, lab reports, miscellaneous forms
NAVMED 6150
Summary of Care form (always on top)
SF 601
Immunization Record
NAVMED 6000/2
Chronological record of HIV testing
DD 771
Eyewear prescription
NAVMED 6490/1
Visual record
NAVMED 6470/10
Occupational exposure to radiation
NAVMED 6470/11
Exposure to radiation from internal radionuclide
DD 2215
Reference audiogram
NAVMED 6260/5
Asbestos medical surveillance program
DD 2216
Annual hearing conservation data
DD2493-1
Asbestos Exposure - Part 1 initial & Part 2 periodic
OPVAV 5100/15
Medical Surveillance Questionnaire
NAVPERS 5510/1
Record identifier for Personnel Reliability Program (PRP)
SF 588
Emergency care & treatment/ ambulance care
SF 600
Chronological record of care
SF 513
Medical record consultation sheet
DD 2161
Referral for civilian medical care
DD 2064
Death Certificate
SF 503
Autopsy protocol
SF 523
Authorization for autopsy
SF 523A
Disposition of body
SF 523B
Authorization for tissue donation
NAVMED 6300/5
Inpatient admission disposition record
SF 502
Narrative Summary
SF 539
Abbreviation Medical Record
SF 509
Progress Notes
SF 516
Operation Report
SF 517
Anesthesia Report
SF 522
Request for Anesthesia
DD 602
Patient Evaluation Tag
NAVMED 1300/1
Medical & Dental overseas screening review for active duty and dependents
NAVPERS 1300/16
Report of suitability of overseas screening
NAVMED 6100/1
Medical board report cover sheet
NAVMED 6100/2
Medical board statement of patient
NAVMED 6100/3
Medical board certificate
NAVMED 6100/5
Abbreviated Medical Evaluation Board Report
DD 2807
Medical History
DD 2808
Medical Examination
DD 2697 is
Report of Medical Assessment
NAVPERS 1745/1
Exceptional Family Member program application
DD 2569
Third Party Collection Program
OPNAV 5211/9
Record of Disclosure (Privacy Act of 1974)
DD 877
Request for Medical & Dental records
SF 515
Tissue Examination
SF 519
Medical record radiographic reports
SF 508
Blood or blood competent transfusion
SF 545
Laboratory report display
SF 511
Vital Signs Record
SF 512
Plotting chart
SF 233
Prenatal and pregnancy civilian medical care notes
SF 2824C
Physician statement for employee disability retirement
SF 47
Physical fitness inquiry for motor vehicle operators
SF 78
Certificate of medical examination
What does DNA stand for
Deoxyribonucleic Acid
NAVMED 6120/2
Officer physical examination special questionnaire
NAVMED 6120/3
Annual certificate physical condition
NAVMED 6150/4
Abstract of Service and medical history
SF 217
Epilepsy medical report
SF 518
Blood or Blood component transfusion
SF 520
Electrocardiogram request
SF 524
Radiation Therapy
SF 525
Radiation Therapy summary
SF 526
Intestinal/ inter-cavity therapy
SF 527
Group muscle strength
SF 53
Neurological Exam
SF 531
Anatomical figure
SF 541
Gynecologic cytology
SF 560
Electroencephalogram request & history.
PHS 731
International Certificates of vaccination; a personal record of immunizations that is not filled in HREC
Dental record part 1 includes
Radiographs
Dental record part 2 includes
NAVMED 6600/3 (dental health questionnaire)
Dental record part 3 includes
Dental exam forms, EZ 603 (dental examination report)
Dental record part 4 includes
Current dental status form, EZ 603A (dental treatment record)
How often are records verified by medical?
Annually
On what occasions are records reviewed?
Reporting, detachment , and all physical exams
How are records sent if they can’t be hand carried during PCS
Send via certified mail with copy of DD 877
How to close a medical record?
Ensure data is consistent and in chronological order and record closing entry with pertinent info on page 4 (NAVMED 6150/4: abstract of service & medical)
How to report MIA members?
Document circumstances of presumed disappearance on SF 600
How to report deserters?
Document on SF 600, EZ 603 and page 4; deliver record to CO