HM Chapter 04: Medical Records Flashcards

0
Q

What are the medical records named?

A

NAVMED 6150/20-29

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1
Q

How many category of records are there?

A

3: health, outpatient, inpatient

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2
Q

Temporary records are also known as

A

Ancillary records

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3
Q

Who has ultimate responsibility for medical records?

A

Commanding Officer

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4
Q

Pencil entries are made….

A

In the first section of medical record in upper left corner; includes command & rank

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5
Q

01-19 is

A

Dependent Child

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6
Q

12 is …

A

Activated reserve

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7
Q

20-29 is …

A

Active Duty

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8
Q

30-39 is

A

Dependent spouse/former spouse

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9
Q

40-44 is …

A

Dependent Mother or Stepmother

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10
Q

45-49 is …

A

Dependent father or stepfather

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11
Q

50-54 is …

A

Dependent mother in law

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12
Q

55-59 is …

A

Dependent father in law

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13
Q

60-69 is …

A

Other authorized dependents

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14
Q

98 is …

A

Civilian employees

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15
Q

99 is …

A

All others

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16
Q

Preparing the medical record includes 3 parts, which are…

A

Part 1: done in pencil
Part 2: Signed DD 2005 (privacy act) in pen
Part 3: Disclosure Accounting Record

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17
Q

What’s the name if the navy’s medical record filing system?

A

Terminal Digit Filing System

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18
Q

NAVMED 6150/20

A

Orange

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19
Q

NAVMED 6150/21

A

Green

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20
Q

NAVMED 6150/22

A

Yellow

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21
Q

NAVMED 6150/23

A

Gray

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22
Q

NAVMED 6150/24

A

Tan

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23
Q

NAVMED 6150/25

A

Blue

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24
Q

NAVMED 6150/26

A

White

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25
Q

NAVMED 6150/27

A

Almond

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26
Q

NAVMED 6150/28

A

Pink

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27
Q

NAVMED 6159/29

A

Pink

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28
Q

NAVMED 6150/7

A

Health Record Receipt (pink card)

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29
Q

What to do for foreign medical records?

A

Enter 00; also NMN is notated on front cover to indicate no middle name.

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30
Q

Located in part 1 of medical record?

A

Record of Preventive & Occupational Health

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31
Q

Located in part 2 of medical record

A

Record of medical care & treatment

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32
Q

Located in Part 3 of medical record

A

Physical qualifications

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33
Q

Located in part 4 of medical records

A

Record of ancillary studies, inpatient care, lab reports, miscellaneous forms

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34
Q

NAVMED 6150

A

Summary of Care form (always on top)

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35
Q

SF 601

A

Immunization Record

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36
Q

NAVMED 6000/2

A

Chronological record of HIV testing

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37
Q

DD 771

A

Eyewear prescription

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38
Q

NAVMED 6490/1

A

Visual record

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39
Q

NAVMED 6470/10

A

Occupational exposure to radiation

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40
Q

NAVMED 6470/11

A

Exposure to radiation from internal radionuclide

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41
Q

DD 2215

A

Reference audiogram

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42
Q

NAVMED 6260/5

A

Asbestos medical surveillance program

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43
Q

DD 2216

A

Annual hearing conservation data

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44
Q

DD2493-1

A

Asbestos Exposure - Part 1 initial & Part 2 periodic

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45
Q

OPVAV 5100/15

A

Medical Surveillance Questionnaire

46
Q

NAVPERS 5510/1

A

Record identifier for Personnel Reliability Program (PRP)

47
Q

SF 588

A

Emergency care & treatment/ ambulance care

48
Q

SF 600

A

Chronological record of care

49
Q

SF 513

A

Medical record consultation sheet

50
Q

DD 2161

A

Referral for civilian medical care

51
Q

DD 2064

A

Death Certificate

52
Q

SF 503

A

Autopsy protocol

53
Q

SF 523

A

Authorization for autopsy

54
Q

SF 523A

A

Disposition of body

55
Q

SF 523B

A

Authorization for tissue donation

56
Q

NAVMED 6300/5

A

Inpatient admission disposition record

57
Q

SF 502

A

Narrative Summary

58
Q

SF 539

A

Abbreviation Medical Record

59
Q

SF 509

A

Progress Notes

60
Q

SF 516

A

Operation Report

61
Q

SF 517

A

Anesthesia Report

62
Q

SF 522

A

Request for Anesthesia

63
Q

DD 602

A

Patient Evaluation Tag

64
Q

NAVMED 1300/1

A

Medical & Dental overseas screening review for active duty and dependents

65
Q

NAVPERS 1300/16

A

Report of suitability of overseas screening

66
Q

NAVMED 6100/1

A

Medical board report cover sheet

67
Q

NAVMED 6100/2

A

Medical board statement of patient

68
Q

NAVMED 6100/3

A

Medical board certificate

69
Q

NAVMED 6100/5

A

Abbreviated Medical Evaluation Board Report

70
Q

DD 2807

A

Medical History

71
Q

DD 2808

A

Medical Examination

72
Q

DD 2697 is

A

Report of Medical Assessment

73
Q

NAVPERS 1745/1

A

Exceptional Family Member program application

74
Q

DD 2569

A

Third Party Collection Program

75
Q

OPNAV 5211/9

A

Record of Disclosure (Privacy Act of 1974)

76
Q

DD 877

A

Request for Medical & Dental records

77
Q

SF 515

A

Tissue Examination

78
Q

SF 519

A

Medical record radiographic reports

79
Q

SF 508

A

Blood or blood competent transfusion

80
Q

SF 545

A

Laboratory report display

81
Q

SF 511

A

Vital Signs Record

82
Q

SF 512

A

Plotting chart

83
Q

SF 233

A

Prenatal and pregnancy civilian medical care notes

84
Q

SF 2824C

A

Physician statement for employee disability retirement

85
Q

SF 47

A

Physical fitness inquiry for motor vehicle operators

86
Q

SF 78

A

Certificate of medical examination

87
Q

What does DNA stand for

A

Deoxyribonucleic Acid

88
Q

NAVMED 6120/2

A

Officer physical examination special questionnaire

89
Q

NAVMED 6120/3

A

Annual certificate physical condition

90
Q

NAVMED 6150/4

A

Abstract of Service and medical history

91
Q

SF 217

A

Epilepsy medical report

92
Q

SF 518

A

Blood or Blood component transfusion

93
Q

SF 520

A

Electrocardiogram request

94
Q

SF 524

A

Radiation Therapy

95
Q

SF 525

A

Radiation Therapy summary

96
Q

SF 526

A

Intestinal/ inter-cavity therapy

97
Q

SF 527

A

Group muscle strength

98
Q

SF 53

A

Neurological Exam

99
Q

SF 531

A

Anatomical figure

100
Q

SF 541

A

Gynecologic cytology

101
Q

SF 560

A

Electroencephalogram request & history.

102
Q

PHS 731

A

International Certificates of vaccination; a personal record of immunizations that is not filled in HREC

103
Q

Dental record part 1 includes

A

Radiographs

104
Q

Dental record part 2 includes

A

NAVMED 6600/3 (dental health questionnaire)

105
Q

Dental record part 3 includes

A

Dental exam forms, EZ 603 (dental examination report)

106
Q

Dental record part 4 includes

A

Current dental status form, EZ 603A (dental treatment record)

107
Q

How often are records verified by medical?

A

Annually

108
Q

On what occasions are records reviewed?

A

Reporting, detachment , and all physical exams

109
Q

How are records sent if they can’t be hand carried during PCS

A

Send via certified mail with copy of DD 877

110
Q

How to close a medical record?

A

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)

111
Q

How to report MIA members?

A

Document circumstances of presumed disappearance on SF 600

112
Q

How to report deserters?

A

Document on SF 600, EZ 603 and page 4; deliver record to CO