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Medical Admin > Military Treatment Record Management > Flashcards

Military Treatment Record Management Flashcards

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USMLE® Step 1 flashcards
1
Q

NAVMED P-117

A

Manual of the Medical Department (MANMED)

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2
Q

What is the purpose of the military treatment record?

A

A chronological record of medical treatment afforded members of the naval service

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3
Q

The military treatment record has current and long-term medico-legal value to who?

A

The individual concerned, Their survivors, U.S. Government.

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4
Q

Health records are used to what?

A
  • Patient care and evaluation
  • Documentary evidence
  • Communication between providers
  • Legal
  • Data collection
  • Justify costs
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5
Q

A new health record is opened when?

A

Initial entry (at MEPS)

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6
Q

When is a dental record created?

A

First dental visit

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7
Q

How do you request records for individuals who have had prior service and have been discharged?

A

From the National Personnel Records Center using DD 877, Request for Medical/Dental Records.

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8
Q

In accordance with Article 23 of the MANMED, a military health treatment record
(HREC) shall be closed when?

A

Will no longer show up to work. (Dies, discharged, resigns, released from active duty, etc.)

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9
Q

Where do you record the closing entries for a record?

A

On NAVMED 6150/4, Abstract of Service and Medical

History

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10
Q

When closing a HREC what should be included along with it?

A

Dental record

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11
Q

The medical record is the property of who?

A

The US Government

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12
Q

Health record procedures when patient is hospitalized at MTF?

A

Include the HREC or OREC and copy of IREC with the patient

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13
Q

Health record procedures when patient is at a Federal Facility?

A

HREC will accompany patient, or send as soon as possible.

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14
Q

Health record procedure when patient is at a VA medical center?

A

Forward a copy of the HREC, all medical boards, and IREC of a patient. Transfer the original HREC to the cognizant MTF.

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15
Q

Disposition procedures of a UA service member?

A

UA in excess of 10 days, send the record to PSD

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16
Q

NAVMED 6150/7

A

Charge out Receipt Card (Pink Card) (Maintained for 1 year after transfer)

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17
Q

In the even a record is lost or unaccounted where would you document this?

A

Administrative remarks (NAVPERS 1070/613 page 13) entry

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18
Q

When a record is lost and replaced what it the jacket labeled with?

A

REPLACEMENT and written on all forms replaced

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19
Q

When a health record approaches a state of illegibility or deterioration what is the jacket labeled with?

A

DUPLICATE RECORD

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20
Q

What system is used to file records?

A

Terminal digit filing system (TDFS), according to a terminal

digit, color-coded, and blocked filing system.

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21
Q

Health record verification should be done when?

A

Upon receipt (check-in), At the time of physical exam/PHA, Before transfer

22
Q

DD 2766

A

Adult Preventive and Chronic Care Flow sheet.

23
Q

NAVMED 6230/4

A

Immunization Record.

24
Q

NAVMED 6000/2

A

Chronological Record of HIV Testing.

25
Q

DD 771

A

Eye Wear Prescription

26
Q

NAVMED 6470/10

A

Record of Occupational Exposure to Ionizing Radiation.

27
Q

NAVMED 6470/11

A

Record of Exposure to Ionizing Radiation from Internally

Deposited Radionuclides.

28
Q

DD 2215

A

Reference Audiogram.

29
Q

DD 2216

A

Hearing Conservation Data, Annual audiogram

30
Q

NAVMED 6224/1

A

TB Contact/Reactor.

31
Q

NAVMED 6260/5

A

Asbestos Medical Surveillance Program.

32
Q

DD 2493-1

A

Asbestos Exposure-Part I, Initial Medical Questionnaire.

33
Q

DD 2493-2

A

Asbestos Exposure-Part II, Periodic Medical Questionnaire.

34
Q

OPNAV 5100/15

A

Medical Surveillance Questionnaire.

35
Q

NAVPERS 5510/1

A

Record Identifier for Personnel Reliability Program (PRP)

36
Q

SF 600

A

Chronological Record of Medical Care.

37
Q

SF 513

A

Consultation Sheet.

38
Q

DD 2005

A

Privacy Act Statement (PREPRINTED)

39
Q

DD 2808

A

Report of Medical Examination (Replaced SF 88)

40
Q

DD 2807-1

A

Report of Medical History (Replaced SF 93)

41
Q

NAVMED 6150/2

A

Special Duty Medical Abstract.

42
Q

NAVMED 6150/5

A

Abstract of Service and Medical History.

43
Q

DD 877

A

Request for Medical/Dental Records.

44
Q

OPNAV 5211/9

A

PREPRINTED: Record of Disclosure

45
Q

NAVMED 1300/1

A

Medical, Dental, and Educational Suitability Screening for

Service and Family Members.

46
Q

EZ 603

A

Dental

47
Q

Hypersensitivity to a drug or chemical is recorded on what?

A

NAVMED 6230/4, Immunization Record under Remarks and Recommendations.
DD 2766, block 1.
Placing an “X” on the front leaf of the health/dental record in the alert box.
SF 600, Chronological Record of Medical Care.

48
Q

What is the purpose of a medical warning tag?

A

To recognize special health problems when:
Medical records are not available.
Patient is unable to give medical history.

49
Q

Dental Class I

A

Having no pathological oral conditions and requiring no treatment.

50
Q

Dental Class II

A

Having minor pathological oral conditions for which early clinical
treatment is indicated.

51
Q

Dental Class III

A

Have pathological oral conditions for which early clinical treatment is indicated.

52
Q

Dental Class IV (4)

A

Dental classification is unknown because they have not received an oral examination by a Dental Officer within the past 12 months or for whom no dental
record exists.

Medical Admin (2 decks)

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