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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
Q

NAVMED 6300/5

A

Inpatient admission/disposition
Part 2 section B

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26
Q

SF 502

A

Narrative summary
Part 2 section B

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27
Q

SF 539

A

Abbreviated medical record
Part 2 section B

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28
Q

SF 509

A

Progress notes
Part 2 section B

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29
Q

SF 516

A

Operation report
Part 2 section B

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30
Q

SF 600

A

Chronological record of medical care
Part 2 section B

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31
Q

SF 517

A

Anesthesia
Part 2 section B

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32
Q

SF 522

A

Request for administration of anesthesia
Part 2 section B

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33
Q

SF 533

A

Prenatal and pregnancy
Part 2 section B

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34
Q

Civilian medical care notes

A

Part 2 section B

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35
Q

DD 602

A

Patient evacuation tag
Part 2 section B

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36
Q

DD 2005

A

Preprinted privacy act statement
Part 2

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37
Q

NAVMED 1300/1

A

Medical/Dental/educational suitability screening for service and family members
Part 3

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38
Q

NAVPERS 1300/16

A

Report of suitability for overseas assignments parts I, II, and III
Part 3

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39
Q

NAVMED 6100/1

A

Medical board report cover sheet
Part 3

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40
Q

NAVMED 6100/2

A

Medical board statement of patient
Part 3

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41
Q

NAVMED 6100/3

A

Medical board certificate relative to a PEB hearing
Part 3

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42
Q

NAVMED 6100/5

A

Abbreviated temporary limited duty
Part 3

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43
Q

SF 2842-C

A

Physicians statement for employee disability retirement
Part 3

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44
Q

SF 47

A

Physical fitness inquiry for motor vehicle operators
Part 3

45
Q

SF 78

A

Certificate of medical examination
Part 3

46
Q

DD 2808

A

Report of medical examination
Part 3

47
Q

DD 2807-1

A

Report of medical history
Part 3

48
Q

BUMED waiver letters with BUPERS endorsement

A

Part 3

49
Q

NAVMED 6120/1

A

Competence of duty examination
Part 3

50
Q

NAVMED 6120/2

A

Officer physical examination special questionnaire
Part 3

51
Q

NAVMED 6120/3

A

Annual certificate of physical condition
Part 3

52
Q

NAVMED 6150/2

A

Special duty medical abstract
Part 3

53
Q

NAVMED 6150/4

A

Abstract of service and medical history
Part 3

54
Q

NAVJAG 5800/10

A

Injury report
Part 3

55
Q

NAVJAG report

A

Part 3

56
Q

DD 2792

A

Exceptional family member program application (EFM)
Part 3

57
Q

DD 2569

A

Third party collection program
Part 3

58
Q

Living will or medical POA

A

Part 3

59
Q

DD 877

A

Request for medical/dental records
Part 3

60
Q

DNA Analysis sample pouch

A

Part 3

61
Q

OPNAV 5211/9

A

Preprinted record of disclosure
Part 3

62
Q

SF 217

A

Medical record - epilepsy
Part 4

63
Q

SF 515

A

Tissue examination
Part 4

64
Q

SF 519A

A

Radiographic report
Part 4

65
Q

SF 519B

A

Radiographic consultation request/report
Part 4

66
Q

SF 518

A

Blood or blood component transfusion
Part 4

67
Q

SF 520

A

Electrocardiogram request
Part 4

68
Q

SF 524

A

Radiation therapy
Part 4

69
Q

SF 525

A

Radiation therapy summary
Part 4

70
Q

SF 526

A

Interstitial/intercavity therapy
Part 4

71
Q

SF 527

A

Group muscle strength, joint ROM, girth, length measurements
Part 4

72
Q

SF 528

A

Muscle function by nerve distribution: face, neck, and upper extremity
Part 4

73
Q

SF 529

A

Muscle function by nerve distribution: truck and lower extremity
Part 4

74
Q

SF 530

A

Neurological examination
Part 4

75
Q

SF 531

A

Anatomical figure
Part 4

76
Q

SF 541

A

Gynecologic cytology
Part 4

77
Q

SF 545

A

Laboratory report display
Part 4

78
Q

SF 546 - 557

A

Laboratory reports
Part 4

79
Q

SF 559

A

Allergen extract prescription
Part 4

80
Q

SF 580

A

Electroencephalogram request and history
Part 4

81
Q

SF 511

A

Vital signs record
Part 4

82
Q

SF 512

A

Plotting chart
Part 4

83
Q

SF 512A

A

Plotting chart - BP
Part 4

84
Q

Purpose of a medical record

A

Chronological record of medical treatment

85
Q

HRECs are used for:

A
  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
Q

When is a new HERC opened?

A

MEPS

87
Q

When is a DREC opened?

A

First initial visit

88
Q

How do you request HREC/DREC for prior service?

A

DD 877

89
Q

Who is the entity that archives records?

A

National personnel records center

90
Q

When do you close a HREC?

A

Death, discharge, resigns, released from AD, retires, transferred to fleet reserves, MIA, deserter, disenrolled from OCS

91
Q

When closing a medical record, what needs to be done?

A

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
Q

Who has custody over records?

A

Primary cognizance (MTF)
SMDR or SMO for ships

93
Q

Hospitalized at MTF?

A

HREC/OREC sent with patient

94
Q

Hospitalized at federal facility?

A

HREC accompany patient or sent ASAP

95
Q

Hospitalized at Veterans administration medical center (VAMC)?

A

Forward copy of HREC, transfer original to cognizant MTF

96
Q

Hospitalized at civilian medical facility?

A

Forward HREC to administrative cognizant

97
Q

Hospitalized at foreign facility?

A

Make entry in HREC
Send HREC to MTF having administrative cognizant
English translation of narrative summary

98
Q

What defines UA?

A

Excess of 10 days, send HREC to PSD

99
Q

How long do you maintain NAVMED 6150/7 aka pink card?

A

1 year after transfer

100
Q

What documents must be included if a HREC is lost or destroyed?

A

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
Q

What classifies a damaged record?

A

Illegible medical record

102
Q

What documents must be included for a damaged health record?

A

Designation “Duplicate” on front leaf
Circumstances annotated on SF 600
“Duplicate” annotated on bottom of each form

103
Q

What is the filing system used for records?

A

Terminal digit filing system (TDFS)

104
Q

How often is a record verified?

A

Upon receipt
At the time of physical examination
Before transfer
At a minimum, annually

105
Q

Where do you document a hypersensitivity for HREC and DREC?

A

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
Q

What are the four dental classes?

A

Class 1 (white)
Class 2 (green)
Class 3 (yellow)
Class 4 (red)

107
Q

Which dental classification affect’s deployability status?

A

Class 3

108
Q

Which dental classification affect’s deployability status?

A

Class 3

Unit 4 Med Admin (7 decks)

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