Medical Records Flashcards
1
Q
Medical Records
A
Military or civilian documents that give information on the evaluation, findings, diagnosis, and treatment of a patient.
Included as medical records are: Service Treatment Records (STR) Outpatient Treatment Records (OTR) Inpatient Treatment Records (ITR) Dental records
2
Q
Paper to AHLTA transition
A
Circa 2001, MTFs began a redundant system of documentation: Paper + Electronic
Providers would type and save, then print and file
Gradual phase out of paper use
100% AHLTA
Paper use when AHLTA malfunctions
1x/month
Scan then append to AHLTA record
