Military Treatment Record Managment

Question 1

Purpose of a military treatment record

Answer 1

A chronological record of medical treatment afforded members of naval service

Question 2

Health Records (HRECs) are used to:

Answer 2

• plan patient care and evaluate the patients condition and treatment
• serve as documentary evidence of the course of care
• document communication between practitioner and all other healthcare professionals who contribute to their care
• provide data for use in continuing research and education

Question 3

you open a record when:

Answer 3

• upon individual entry into regular or reserve naval service. (done at MEPS)
• dental is made at first visit

Question 4

form used to request a medical record from National Personnel Records Center

Answer 4

DD 877, Request for medical / Dental Records

Question 5

When to close an HREC

Answer 5

• Death
• Discharge
• Resigns (Officers)
• Retires
• Transferred to fleet reserve
• Declared Missing in action
• declared a deserter
• disenrolled from officer candidate programs

Question 6

How many days of UA till the record is sent to PSD

Answer 6

10 Days

Question 7

NAVMED 6150/7

Answer 7

Charge out Receipt Card (Pink Card)

Question 8

Process for PCSing member

Answer 8

• Include Dental Record
• Member may handcarry
• Complete record of charge out
• Fillout Pink Card stating member transferred
• retain Pink Card for 1 year

Question 9

Form to fill out if HREC is lost or destroyed

Answer 9

NAVPERS 1070/613

Question 10

When do you verify records?

Answer 10

• Upon check-in
• At the time of physical examination
• Before Transfer
• At least annually

Question 11

how to make Corrections to entries in an HREC

Answer 11

• preferably made by the originator of the document being changed
• Single line and initial
• explain why the alteration was made

Question 12

Section 1 of the HREC

Answer 12

Record of Preventative medicine and occupational health

• DD 2766 Adult Preventive and chronic care flowsheet
• NAVMED 6230/4 IMMZ Record
• NAVMED 6000/2 Chronological record of HIV Testing
• DD 2215 Reference Audiogram
• DD 2216 Hearing conservation data
• OPNAVINST 5100/15 Medical Surveillance questionnaire

Question 13

Section 2 of HREC

Answer 13

Record of Medical Care and Treatment

- SF 600 Chronological Record of medical care

Question 14

Section 3 of HREC

Answer 14

Physical Qualifications, Admin forms

• NAVMED 1300/1, Med/Dent/Edu suitability screening for service and family
• NAVMED 1300/2, Med/Dent/Edu suitability screening Checklist
• NAVPERS 1300/16, Report of suitability for overseas assignment
• DD 2808, Report of medical examination
• DD 2807, Report of medical history
• NAVMED 6150/4 Abstract of service and medical history

Question 15

Section 4 of HREC

Answer 15

Record of ancillary studies

• X-rays
• Labs
• electrocardiogram
• Neurological exam
• gynecologic exam

Question 16

NAVMED 6230/4

Answer 16

Immunization record under remarks and recommendation

Question 17

Dental Class 1

Answer 17

individuals with no pathological oral conditions requiring treatment

Question 18

Dental Class 2

Answer 18

individuals with minor pathological oral conditions for which early clinical treatment is indicated

Question 19

Dental class 3

Answer 19

individuals with pathological oral conditions which early treatment is indicated

Question 20

Dental class 4

Answer 20

classification is unknown due to not having an exam done within 12 months or no record exists

Question 21

DD 2766

Answer 21

Section 1

Adult Preventative and Chronic care flowsheet

Question 22

DD 2215

Answer 22

Section 1

Reference Audiogram

Question 23

SF 513

Answer 23

Section 2

- consultation sheet

Question 24

SF 522

Answer 24

Section 2

- Request for administration of anesthesia

Question 25

how to document a hypersensitivity prior to receiving dental care due to congenital heart condition?

Answer 25

Enter in red across the top of EZ 603/ 603A