NAVMED P-117 ch 16 med records Flashcards
What are the three major categories of primary health records?
Health record (HREC)
Out patient record (OREC)
In patient record ( IREC)
What is the purpose of the medical record?
Provide an individual chronological record of medical treatment
What is the health record used for federal civil service employees?
EMF employee medical file
A file of continuous care which documents ambulatory care by a person other than an ADSM.
Outpatient record
Secondary records are made up of what three types of records?
Convenience record
Temporary record
Ancillary record
Temporary and ancillary medical records will not be kept of ADSM except what three special situations?
OB/GYN
Family advocacy
Psyc
What is he NAVMED 6150/20
Summary of care
What are four reasons to maintain secondary medical records?
1) ensure privacy of the patient
2) prevent accidental or deliberate loss of valuable information
3) keep the primary record free of voluminous documents
4) segregate sensitive patient information
What is he purpose of the convenience record?
Allow clinics, services, or department to keep some information from the primary record available. Once no longer needs to be compared to primary to add anything
What is the purpose of a temporary record?
Ensure timely availability of information and documents to specialty clinics, services, and departments
To save money instead of using typical medical record jackets, you can make a temporary record out of what?
Manila folder
What information must be on the front of a temporary medical record?
Name
FMP/SSN
Name of clinic maintaining record
Name of mtf
Why would ancillary records be used?
Patient health information that is withheld from from their primary record
What are two examples of why an ancillary record would be used?
-Information that could be injurious to the patient
-Information that requires extraordinary degrees of protection due to the sensitivity of the information contained
Psychiatric treatment, instances of real or suspected child or spouse abuse
Where would you place the stamp “secondary record” on a medical record used for ancillary reasons?
Front between the patients ID block and and the alert box
1/4 inch letters
Mark, “X” in the outpatient box
mark on the primary record, “secondary record exist”*
If transfer is necessary how can ancillary records be moved from one MTF to anther?
In a double sealed envelope
Label the outside one:
FOR COMMANDING OFFICER’S EYES ONLY
label the inside envelop:
For official use only-restricted circulation
In 1/4 inch block letters and identify the clinic where the record is to be maintained
If ancillary record is not combined with primary record when it is closed, due to providers request, what will the medical record administrator do?
Retire it separately to the NPRC. The MRB must maintain a log that identifies when and where the record was retired.
Ancillary records can be viewed by what four people or groups?
Court of law
Patient review
Available to investigative bodies, NCIS
Protected from people outside of the law
When would medical records not need to be locked up?
If under a 24 hour watch
Medical Records are property of whom?
He US government
To avoid the frequent hand caring of records by patients the MTF were DTF should establish what systems?
Systems that allow delivery of records to clinics for scheduled appointments as well as The return back to the medical record department
What to system should be used to check medical and dental records out and in?
DEERS
CHCS
Who is responsible for the administration of the Navy’s medical records program?
BUMED patient admin division, medical records branch
Prepare what color EMF folder upon entry of an employee into the federal civil service?
Blue
