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Unit 4 Med Admin > Medical Record > Flashcards

Medical Record Flashcards

1
Q

DD2766

A

Adult preventative and chronic care flow sheet
Part 1

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2
Q

NAVMED 6230/4

A

Immunization record
Part 1

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3
Q

NAVMED 6000/2

A

Chronological record of HIV testing
Part 1

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4
Q

DD771

A

Eye wear prescription
Part 1

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5
Q

NAVMED 6470/10

A

Record of occupational exposure to ionizing radiation
Part 1

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6
Q

NAVMED 6470/11

A

Record of exposure to ionizing radiation from internally deposited radionuclides
Part 1

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7
Q

DD2215

A

Reference audiogram
Part 1

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8
Q

DD2216

A

Hearing conservation program
Part 1

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9
Q

NAVMED 6224/1

A

TB contact/reactor
Part 1

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10
Q

NAVMED 6260/5

A

Asbestos medical surveillance program
Part 1

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11
Q

DD2493-1

A

Asbestos exposure part 1 initial medical questionnaire
Part 1

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12
Q

DD2493-2

A

Asbestos exposure part 2 periodic medical questionnaire
Part 1

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13
Q

OPNAV 5100/15

A

Medical surveillance questionnaire
Part 1

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14
Q

Other 5100 forms

A

Occupational health series forms
Part 1

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15
Q

NAVPERS 5510/1

A

Record identifier for personal reliability program (PRP)
Part 2

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16
Q

SF558

A

Medical record emergency care and treatment
Part 2

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17
Q

SF600

A

Chronological record of medical care
Part 2

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18
Q

DD513

A

Consultation sheet
Part 2

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19
Q

DD2161

A

Referral for civilian medical care
Part 2

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20
Q

DD2064

A

Certificate of death
Part 2 section A

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21
Q

SF 503

A

Autopsy protocol
Part 2 section A

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22
Q

SF 523

A

Authorization for autopsy
Part 2 section A

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23
Q

SF 523A

A

Disposition of body
Part 2 section A

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24
Q

SF 523B

A

Authorization for tissue donation
Part 2 section A

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25
NAVMED 6300/5
Inpatient admission/disposition Part 2 section B
26
SF 502
Narrative summary Part 2 section B
27
SF 539
Abbreviated medical record Part 2 section B
28
SF 509
Progress notes Part 2 section B
29
SF 516
Operation report Part 2 section B
30
SF 600
Chronological record of medical care Part 2 section B
31
SF 517
Anesthesia Part 2 section B
32
SF 522
Request for administration of anesthesia Part 2 section B
33
SF 533
Prenatal and pregnancy Part 2 section B
34
Civilian medical care notes
Part 2 section B
35
DD 602
Patient evacuation tag Part 2 section B
36
DD 2005
Preprinted privacy act statement Part 2
37
NAVMED 1300/1
Medical/Dental/educational suitability screening for service and family members Part 3
38
NAVPERS 1300/16
Report of suitability for overseas assignments parts I, II, and III Part 3
39
NAVMED 6100/1
Medical board report cover sheet Part 3
40
NAVMED 6100/2
Medical board statement of patient Part 3
41
NAVMED 6100/3
Medical board certificate relative to a PEB hearing Part 3
42
NAVMED 6100/5
Abbreviated temporary limited duty Part 3
43
SF 2842-C
Physicians statement for employee disability retirement Part 3
44
SF 47
Physical fitness inquiry for motor vehicle operators Part 3
45
SF 78
Certificate of medical examination Part 3
46
DD 2808
Report of medical examination Part 3
47
DD 2807-1
Report of medical history Part 3
48
BUMED waiver letters with BUPERS endorsement
Part 3
49
NAVMED 6120/1
Competence of duty examination Part 3
50
NAVMED 6120/2
Officer physical examination special questionnaire Part 3
51
NAVMED 6120/3
Annual certificate of physical condition Part 3
52
NAVMED 6150/2
Special duty medical abstract Part 3
53
NAVMED 6150/4
Abstract of service and medical history Part 3
54
NAVJAG 5800/10
Injury report Part 3
55
NAVJAG report
Part 3
56
DD 2792
Exceptional family member program application (EFM) Part 3
57
DD 2569
Third party collection program Part 3
58
Living will or medical POA
Part 3
59
DD 877
Request for medical/dental records Part 3
60
DNA Analysis sample pouch
Part 3
61
OPNAV 5211/9
Preprinted record of disclosure Part 3
62
SF 217
Medical record - epilepsy Part 4
63
SF 515
Tissue examination Part 4
64
SF 519A
Radiographic report Part 4
65
SF 519B
Radiographic consultation request/report Part 4
66
SF 518
Blood or blood component transfusion Part 4
67
SF 520
Electrocardiogram request Part 4
68
SF 524
Radiation therapy Part 4
69
SF 525
Radiation therapy summary Part 4
70
SF 526
Interstitial/intercavity therapy Part 4
71
SF 527
Group muscle strength, joint ROM, girth, length measurements Part 4
72
SF 528
Muscle function by nerve distribution: face, neck, and upper extremity Part 4
73
SF 529
Muscle function by nerve distribution: truck and lower extremity Part 4
74
SF 530
Neurological examination Part 4
75
SF 531
Anatomical figure Part 4
76
SF 541
Gynecologic cytology Part 4
77
SF 545
Laboratory report display Part 4
78
SF 546 - 557
Laboratory reports Part 4
79
SF 559
Allergen extract prescription Part 4
80
SF 580
Electroencephalogram request and history Part 4
81
SF 511
Vital signs record Part 4
82
SF 512
Plotting chart Part 4
83
SF 512A
Plotting chart - BP Part 4
84
Purpose of a medical record
Chronological record of medical treatment
85
HRECs are used for:
1. Plan patient care and evaluate conditions 2. Furnish documentary evidence 3. Document communication between MO’s 4. Assist in protecting legal interest 5. Provide data 6. Justify 3rd party costs 7. Serve as communication among HCP, utilization management, risk management
86
When is a new HERC opened?
MEPS
87
When is a DREC opened?
First initial visit
88
How do you request HREC/DREC for prior service?
DD 877
89
Who is the entity that archives records?
National personnel records center
90
When do you close a HREC?
Death, discharge, resigns, released from AD, retires, transferred to fleet reserves, MIA, deserter, disenrolled from OCS
91
When closing a medical record, what needs to be done?
Record closing entries on NAVMED 6150/4 Ensure record is in order, no loose papers All pertinent documents are included Provide copy, if requested Ensure original sep physical is included Dental and medical records are sent together
92
Who has custody over records?
Primary cognizance (MTF) SMDR or SMO for ships
93
Hospitalized at MTF?
HREC/OREC sent with patient
94
Hospitalized at federal facility?
HREC accompany patient or sent ASAP
95
Hospitalized at Veterans administration medical center (VAMC)?
Forward copy of HREC, transfer original to cognizant MTF
96
Hospitalized at civilian medical facility?
Forward HREC to administrative cognizant
97
Hospitalized at foreign facility?
Make entry in HREC Send HREC to MTF having administrative cognizant English translation of narrative summary
98
What defines UA?
Excess of 10 days, send HREC to PSD
99
How long do you maintain NAVMED 6150/7 aka pink card?
1 year after transfer
100
What documents must be included if a HREC is lost or destroyed?
Page 13 or NAVPERS 1070/613 Designation of “Replacement” on front leaf Synopsis of replacement on SF 600 “Replacement” annotated on bottom of each form
101
What classifies a damaged record?
Illegible medical record
102
What documents must be included for a damaged health record?
Designation “Duplicate” on front leaf Circumstances annotated on SF 600 “Duplicate” annotated on bottom of each form
103
What is the filing system used for records?
Terminal digit filing system (TDFS)
104
How often is a record verified?
Upon receipt At the time of physical examination Before transfer At a minimum, annually
105
Where do you document a hypersensitivity for HREC and DREC?
NAVMED 6230/4 under remarks and recommendations DD 2766 block 1 “X” on alert box on front leaf SF 600 Red Cross top of EZ603/603A
106
What are the four dental classes?
Class 1 (white) Class 2 (green) Class 3 (yellow) Class 4 (red)
107
Which dental classification affect’s deployability status?
Class 3
108
Which dental classification affect’s deployability status?
Class 3

Unit 4 Med Admin (7 decks)

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