Medical Records Intro

Question 1

What is the document outlining Medical Record Administration and Healthcare Documentation in the army

Answer 1

AR 40-66

Question 2

Medical Records Definition

Answer 2

military or civilian documents that give information on the evaluation, findings, diagnosis, and treatment of a patient

Question 3

Types of Medical Records (4)

Answer 3

Service Treatment Records (STR)
Outpatient Treatment Records (OTR)
Inpatient Treatments Records (ITR)
Dental Records

Question 4

Defense Health Information Systems (DHIMS) (3)

Answer 4

CHCS I (composite HC system/ foundation/ book appts, pharmacy, lab and radiology)

CHCS II = AHLTA (outpatient use, DoD EHR)

Essentris-inpatient documentation system

Question 5

Medical Uses for Med Records (5)

Answer 5

1. chronological record of med care (including rationale for care)
2. means of communication among med personnel
3. planning/continuity
4. review/eval and study
5. data for research

Question 6

Legal Use of Med Recrods (5)

Answer 6

evidence for…
malpractice
disability and med retirement (insurance)
criminal investigation
external licensure/ accreditation
military line of duty investigations/ med boards

Question 7

Military Use for Med Records (4)

Answer 7

advise CDR on retention/utilization
assist PEBs
mobilization process for active and guard
identify deceased (dental records)

Question 8

Med Records are owned by who? Kept where?

Answer 8

owned by US Government
custody of MTF
AHLTA hard copies in NPRC
STR copy and dental is retired to veterans affairs record center

Question 9

Who in the MTF has custodial responsibility of records

Answer 9

commander of treatment facility
chief of clinical services (DCCS)
attending physician
other professionals attending the patient
hospital registrar

Question 10

Classification of Med Records

Answer 10

Private–limited access for official purposes

Question 11

Who can look at military med record

Answer 11

Patient
medical personnel authorized to diagnose, assess, and treat
(maybe unit personnel officer, inspectors, unit commanders)

Question 12

STR

Answer 12

Service Treatment Record
Primarily Maintained in AHLTA
Outpatient medical and dental care (perm and continuous upon entry into service)

Question 13

OTR

Answer 13

Outpatient treatment record

used to document med and dental care for beneficiaries for whom an STR is not kept

Question 14

Content of outpatient med records

Answer 14

(treated but not admitted to MTF)
physical exam
initial eval/follow up/treatment/discharge
immunization/lab/x-ray
referrals
master problem list
chronological record of visits

Question 15

Inpatient med records: for who and for what??

Answer 15

(MTF with authorized beds for inpatient care)
applies to all beneficiaries
begins upon admisssion, completed w/ end of hospitlization (could have more than 1)

Question 16

ITR contents

Answer 16

inpatient medical record

• -Cover sheet
• -Admission summary
• -History and physical
• -Physical exam & doctor’s progress notes
• -nursing notes; temp; pulse; respiration
• -consultation sheets (labs/x-rays)
• -doctor’s orders
• -narrative summary of hospital stay (pt gets copy)

Question 17

Common Forms for PTs (4)

Answer 17

SF 513: consultation request (referral to PT, or PT referral to other specialist)

SF600: Chronological record of care

DA 3349: Physical profile

SF 509: Progress Notes (inpatient)

Question 18

FM Prefix: 20

Answer 18

sponsor, active duty or retired

Question 19

FM Prefix: 30

Answer 19

souse of sponsor

Question 20

FM Prefix: 31

Answer 20

second spouse

Question 21

FM Prefix: 01

Answer 21

First child of sponsor

Question 22

FM Prefix: 02

Answer 22

second child of sponsor

Question 23

FM Prefix: 40

Answer 23

mother

Question 24

FM Prefix: 45

Answer 24

father

Question 25

FM Prefix: 50

Answer 25

mother-in-law

Question 26

FM Prefix: 55

Answer 26

father-in-law

Question 27

FM Prefix: 60

Answer 27

relative, not immediate family

sister is included in this

Question 28

FM Prefix: 00/98

Answer 28

Civilian emergency

Question 29

Documentation Guidelines (1-7)

Answer 29

1. black ink
2. pt statements in quotes
3. enter only facts
4. standard abbreviations
5. date/time on all entries
6. print name/use stamp
7. don’t obliterate anything (line through mistakes)

Question 30

Documentation guidelines (8-14)

Answer 30

8. do not squeeze afterthoughts in the margin
9. complete, accurate, legible
10. proper documentation format
11. note the date when documenting a return visit
12. document lack of compliance (missed appts)
13. no uncomplimentary comments
14. support fellow HCPs