Military Treatment Record Management Flashcards
HREC opened if…
Initial entry into regular or reserve service
DREC is opened at first dental visit
HREC Closed if…
- Dies/declared dead
- Is discharged
- Resigns (Officers ONLY)
- Is released from active duty
- Retires
- Is transferred to the Fleet Reserve and released to inactive duty
- Is declared missing or missing in action
- Is declared a deserter
- Is dis-enrolled from officer candidate or midshipman programs
NAVMED P117
Manual of Medicine
Chapter 16
Medical Records
Purpose of a military treatment record
- Chronological record of tx
- Medico-legal
- Continuing education
- 3rd party billing
Custodial responsibility
SMDR delegated by CO
LOST/DAMAGED HREC
“REPLACEMENT” on record jacket
Open new HREC
Page 13 (NAVPERS 1070/613)
SF 600 explaining reason for replacement
(If record is found, insert forms into original record)
DESTROYED HREC
“DUPLICATE” on record jacket above treatment record
- Write duplicate on the bottom of each form
- SF 600 explaining why
- Microfiche/Manila envelope permanent file at the bottom right side of part 2 medical record jacket
If a SM is UA for greater than how many days ___ , what do you do with the record?
< 10days
Send record to PSD or unit holding service/pay record
Filing of HRECs
Terminal Digit Filing System (TDFS)
HRECs are filed based off the 2nd to last digit of the last 4
When do you do HREC Verification?
- ANNUALLY
- Check in
- PE
- Check out
Where do you document record verification?
-SF 600
-Mark through current year
-Inside of health record jacket front leaf
(must be written in pencil and kept updated)
Corrections to Entries
- Can be made by authorized personnel, preferably the person who made the original entry
- One line and initial
- Add new info, date, and sign w/ full ID
- explain why correction was made
Part 1: Left Side of HREC
Record of Preventative Medicine and Occupational Health
Part 2: Right Side of HREC Section A
Record of Medical Care and Treatment
Part 2: Right Side of HREC (Section B)
Inpatient Care, Ambulatory Surgeries, etc
Part 3: Left Side of HREC
Physical Qualifications, Administrative Forms
Part 4: Right Side of HREC
Record of Ancillary Studies, Therapies, etc
How to file forms
Chronological order most current form on top
Documentation of Visits must include:
Date: 14FEB22
MTF Name: USS LUNA
Clinic dept: Medical
HCP’s name, rank, profession, and last 4:HM2 Luna SMDR 0015
C/C and Subjective hx
Objective findings
Diagnosis
Modalities; labs, x-rays
Therapies administered
Disposition
Sig
Where are Hypersensitivities documented on a HREC?
NAVMED 6230/4 (remarks)
DD 2766 (block 1)
X on alert box of front record jacket
SF 600 “medical warning tags”
DREC (enter in RED across EZ 603/603A)
What’s the purpose of a medical warning tag?
- recognize a special health problem
- medical record is not available
- pt is unable to give medical hx
4 Dental Classifications
1) White: requires no tx
2) Green: minor w/ early clinical tx
3) Yellow: early clinical tx is indicated
4) Red: class unknown no oral exam in past 12 mon
If someone Commissions…
They keep the same record
Document on SF 600
Abstract of Duty 6150/4
Is Someone is Transferring…
Record Verification
Send Dental record with them
Keep pink slip for 1 year
When is a HREC closed?
When a SM dies, no longer in the Navy, retires/separates.
Who is responsible for administering Privacy Act for the Navy
Chief of Naval Operations
Who is responsible for administering Privacy Act for Marine Corps
Commandant of the Marine Corps
How are records filed?
Terminal Digital Filing System (TDFS)
Who does the record have medical legal value to?
- individual
- their survivors
- gov’t
What’s the purpose of a Health Records?
- medical/legal value
- documentation
- continuing education and research
- continuity of care between health care professionals
- Assist in protecting the legal interest of the patient, the Medical Treatment Facility (MTF) or Dental Treatment Facility (DTF), the practitioner responsible for the patient, the USN, and the U.S. Government
- Justify costs incurred by third party payers
- Serve as a vehicle for communication among health care providers, utilization management, risk management, quality assurance, medical records personnel, and outside agencies
For individuals who have had prior service and have been discharged, who do you request their HREC and DREC from?
National Personnel Records Center
What form do you use to request Medical/ Dental Records?
DD 877
When a midshipmen or enlisted member is appointed to commissioned or warrant grade, what do you do with the existing HREC?
- Continue using it
- Make necessary entries to indicate new grade
- Additionally document on SF 600
- And on NAVMED 6150/4 to include date, place, and grade to which appointed
Where and what do you document when you close a HREC?
NAVMED 6150/4, Abstract of Service and Medical History
-Include the following:
Date of separation
Title of servicing activity
Any explanatory circumstances
The medical record is the property of who?
The U.S. Gov’t
If a SM is Hospitalized at an MTF/Federal Facilities, what do you do with the HREC?
HREC will accompany patient, or send as soon as possible
If a SM is Hospitalized at a Civilian Facility, what do you do with the HREC?
Forward HREC if member’s length of stay warrants the transfer
If a SM is Hospitalized in a Foreign nation facility, what do you do with the HREC?
- Document on SF600
- Send HREC to MTF having administrative cognizance
- place translated narrative summary in HREC
Admission to hospital in foreign nation:
- Make entry of that fact in HREC
- Send HREC to MTF having administrative cognizance
- If applicable, place English translation of the narrative summary in the HREC
Describe the disposition procedures for the military treatment records in the event of unauthorized absence.
If a patient is UA more than 10 days, send the record to PSD or unit holding member’s service/pay record
What info must be recorded on a 6150/7 when checking out a record?
- Prefix code and SSN
- Member’s name
- Ship/station
- date, received by, and location.
Signatures in a military HREC must include:
- signer’s name
- grade
- profession/corps
- last 4 SSN
What dental classifications are deployable?
1 and 2
What needs to be documented on NAVMED 6150/7 when a record is checked out?
- Name
- Prefix code and SSN
- Ship/station
- Date
- Received By
- Location
Transfer to a new duty station
Verify HREC
Include DREC
Hand Carry record
Fill NAVMED 6150/7 “Pink card”
maintain record of transfer for 1 year
Include SAMS transfer disk
Signatures in the HREC should include:
-name
-grade
-rate
last 4 SSN
Documentation of Visits:
- Date
- MTF Name
- Clinic department or service
- HCP’s name, grade or rate, profession and last four of SSN
- Chief complaint
- Objective findings
- Diagnosis
- Studies ordered labs or x-ray
- Therapies administered
- Disposition
- Signature
What 4 things can be found in the OPNAVNOTE 5400?
- proper mailing addresses
- titles of Naval correspondence
- homeports of ships/squadrons
- command UICs
