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