MEDICAL RECORDS Flashcards
DOCUMENT THAT GOVERNS USE OF MEDICAL RECORDS:
NAVMED P=117 MANMED, CHAPTER 16
PURPOSE OF THE MILITARY TREATMENT RECORD:
A CHRONOLOGICAL RECORDS OF MEDICAL TREATMENT
MEDICAL RECORDS HAS LONG TERM MEDICO-LEGAL VALUE TO:
1- THE INDIVIDUAL
2- SURVIVORS
3- US GOVT
HEALTH RECORDS ARE USED TO:
1- PLAN PT CARE/EVALUATE CONDITION AND TREATMENT
2-DOCUMENTARY EVIDENCE
3-DOCUMENT COMMUNICATION BETWEEN ALL PROVIDERS IN CARE OF PT
4-LEGAL PROTECTION
5-PROVIDE DATE FOR EDUCATION AND RESEARCH
6-JUSTIFY COSTS BY 3RD PARTIES
7-VEHICLE FOR COMMUNICATION BETWEEN PROVIDERS AND MEDICAL STAFF
WHEN ARE HRECs OPENED
UPON INITIAL ENTRY INTO REGULAR OR RESERVE SERVICE
-USUALLY DONE AT MEPS
WHEN ARE DENTAL RECORDS OPENED
AT THE FIRST DENTAL VISIT
OBTAINING RECORDS FOR PRIOR SERVICE AFTER DISCHARGE
ORDER HREC/DREC FROM NATIONAL PERSONNEL RECORDS CENTER
-DD877, REQUEST FOR MEDICAL/DENTAL RECORDS
GUIDANCE FOR CLOSING HRECs
ARTICLE 23 OF MANMED
WHEN WOULD YOU CLOSE A RECORD
1- DIES 2-DISCHARGED 3-RESIGNS 4-RELEASED FROM ACTIVE DUTY 5-RETIRES 6- FLEET RESERVE 7-MISSING/MIA 8-DESERTER 9-DIS-ENROLLED FROM OFFICER PROGRAMS
WHERE DO YOU RECORD CLOSING ENTRIES?
NAVMED 6150/4
ABSTRACT OF SERVICE AND MEDICAL HISTORY
WHO HAS CUSTODIAL RESPONSIBILITIES?
SHORE?
SHIP?
MEDICAL RECORDS IS US GOVT PROPERTY, MAINTAINED BY MTF OR DTF
SHIP- SMDR HAS CUSTODIAL RESPONSIBILITIES, BY AUTHORITY DELEGATED BY CO
WHAT TO DO WITH MEDICAL RECORDS IN EVENT OF HOSPITALIZATION
- TRANSFERRED TO FEDERAL FACILITY
- TRANSFERRED TO VA
- HOSPITALIZED AT CIVILIAN HOSPITAL
- HOSPITALIZED IN FOREIGN NATION
AT MTF- HREC GOES WITH PT
AWAY FROM MTF- FORWARD UPON REQUEST
-HREC WILL ACCOMPANY PT OR BE SENT ASAP
-FORWARD A COPY OF HREC TO VA
SEND ORIGINAL TO COGNIZANT MTF
-FORWARD HREC TO MEDICAL FACILITY HAVING ADMIN COGNIZANCE IF NEEDED FOR STAY
- SEND HREC TO MTF WITH ADMIN COGNIZANCE
- ENSURE ENLGISH TRANSLATION IS SUBMITTED INTO HREC
DISPOSITION OF RECORDS IN EVENT OF UA
-US EXCESS OF 10 DAYS, SEND RECORD TO PSD
RECORD DISPOSITION WHEN TRANSFERRING
VERIFY HREC INCLUDE DREC MEMBER CAN HAND CARRY COMPLETE PINK CARD, NAVMED 6150/7, CHARGE OUT RECEIPT CARD (KEEP PINK CARD FOR 1 YEAR)
WHAT TO DO IF A RECORD IS LOST OR DAMAGED
- WHAT FORMS TO FILL OUT
- WHO MAKES IT
1- FILL OUT PAGE 13, NAVPERS 1070/13 AND SF 600
2- COGNIZANT CUSTODIAN MAKES NEW RECORD
3-WRITE REPLACEMENT OVER FRONT JACKET, OR ANY REPLACED FORMS
DESTROYED HEALTH RECORDS
DUPLICATE THE RECORD CLOSE TO ORIGINAL
WRITE DUPLICATE OVER FRONT JACKET, OR DUPLICATE ON BOTTOM OF EACH FORM
SF 600 EXPLAINING DETAILS OF DAMAGE
MICROFICHE ALL FORMS AND PUT INTO ENVELOPE AND ATTACH TO RECORD
WHEN DO RECORDS GET VERIFIED
- CHECK IN
- PHA, PHYSICAL EXAMS
- CHECK OUT
- MUST BE DONE AT LEAST ANNUALLY*
DD 2766
ADULT PREVENTATIVE AND CHRONIC CARE FLOW SHEET
NAVMED 6230/4
IMMS RECORD
NAVMED 6000/2
HIV TESTING
DD 771
EYEWEAR PRESCRIPTION
NAVMED 6470/10
RECORD OF OCCUPATIONAL EXPOSURE TO RADIATION
DD 2215
REFERENCE AUDIOGRAM
DD 2216
HEARING CONSERVATION DATA
