NAVEDTRA 14295B CH 4 Flashcards
What U.S. Navy Medical Outpatient and Dental Treatment Record do Navy and Marine Corps personnel as well as DoD eligible beneficiaries utilize as their official record jacket for the chronological documentation of medical and dental evaluations, care, treatments and occupational health?
NAVMED 6150/21-30
What medical records are used for the documentation of outpatient medical and dental care?
Primary
What is a file of continuous care given to active duty members that documents all outpatient care provided during their career?
HREC
What contains all the dental care documentation provided during a member’s career?
DREC
What file of continuous care documents the ambulatory treatment received by a person other than an active duty person, i.e. retiree and family members?
OREC
What medical file documents the care provided to a patient assigned to a designated inpatient bed at an MTF or ship?
IREC
Opening a secondary medical record requires the healthcare provider to write a note on what form in the primary treatment record?
DD Form 2766
What record contains the excerpts from a patient’s primary record which is kept within the MTF by a treating clinic, service, department, or individual provider for increased access to the information?
Convenience
What records consist of original healthcare documentation withheld from a patient’s primary HREC or OREC?
Ancillary
What system does the Navy Medical Department use to file health records?
Terminal Digit Filing System (TDFS)
Approximately how many equal sections are the central files divided into under the Terminal Digit Filing System?
100
Also known as the pink card, what charge out Form Health Record Receipt will be used for the charge out control of medical records?
NAVMED 6150/7
Records charged out from the file should be returned within how many working days or as soon as possible after the patient’s visit?
5
What may be used in conjunction with the charge out form when open-shelf filing is used for records?
Charge out guide
How often are all records verified by medical and dental personnel having custody of them?
Annually
What form will the HM make an entry for medical records as well as blacking-out the corresponding year block on the front leaf of the jacket with a black felt-tip pen upon completion of an annual medical record verification?
SF 600
Upon final discharge or death the completed and verified health and dental records must be sent to the command maintaining the member’s service record (no later than how many days following separation) for inclusion in and transmittal with the member’s service record?
One day
How long should loose forms be retained after reasonable search efforts do not locate the record?
1 year
What form aids healthcare providers by allowing them quick access to pertinent medical factors that may affect how they manage a patient’s medical care?
DD Form 2766
How many pages is the DD Form 2766 divided into?
4
What form provides a continuous comprehensive record of a patient’s medical history?
SF 600
What form is routinely used for inpatient admission notes and is filed in the patient’s IREC?
SF 509
When a member of the naval service incurs an injury that might result in permanent disability or results in a physical inability to perform duty for a period exceeding how many hours, an entry will be made concerning line-of-duty misconduct?
24
In what series is the specific protocol for recording anthrax immunizations outlined in?
SECNAVINST 6230.4
Refer to BUMEDINST 6224.8 series Tuberculosis Control Program for guidance when recording positive results (of how many mm or more induration) of the tuberculin skin test (TST)?
10
What form should any immunizations recorded on the PHS-731 be transcribed onto?
DD Form 2766
According to international rules, entries on the PHS-731 require authentication for immunizations against smallpox (if administered), yellow fever, cholera, and what else?
Anthrax
What form is initiated when military personnel are first exposed to ionizing radiation (with the exception of patients incurring such radiation while undergoing diagnostic treatment)?
DD FORM 1141
What form is used to summarize clinical data relative to treatment received during periods of hospitalization?
SF 502
The SF 539 may be used as a substitute for the narrative summary for those admissions of a minor nature that require less than how many hours of hospitalization?
48
What form is used for outpatients who need to be referred to other healthcare providers or specialists, such as gynecologists, internists, optometrists, etc…?
SF 513
What form is used to order corrective prescription eyewear?
DD from 771
Who is the official responsible for the administration and supervision of the execution of the SECNAVINST 5211.5 series, Department of the Navy Privacy Act Program (PAP), as it pertains to the Health Care Treatment Record System?
Surgeon General of the Navy
