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advancement instructions > NAVMED P-117 ch 16 med records > Flashcards

NAVMED P-117 ch 16 med records Flashcards

0
Q

What are the three major categories of primary health records?

A

Health record (HREC)
Out patient record (OREC)
In patient record ( IREC)

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1
Q

What is the purpose of the medical record?

A

Provide an individual chronological record of medical treatment

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2
Q

What is the health record used for federal civil service employees?

A

EMF employee medical file

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3
Q

A file of continuous care which documents ambulatory care by a person other than an ADSM.

A

Outpatient record

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4
Q

Secondary records are made up of what three types of records?

A

Convenience record
Temporary record
Ancillary record

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5
Q

Temporary and ancillary medical records will not be kept of ADSM except what three special situations?

A

OB/GYN
Family advocacy
Psyc

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6
Q

What is he NAVMED 6150/20

A

Summary of care

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7
Q

What are four reasons to maintain secondary medical records?

A

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

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8
Q

What is he purpose of the convenience record?

A

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

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9
Q

What is the purpose of a temporary record?

A

Ensure timely availability of information and documents to specialty clinics, services, and departments

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10
Q

To save money instead of using typical medical record jackets, you can make a temporary record out of what?

A

Manila folder

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11
Q

What information must be on the front of a temporary medical record?

A

Name
FMP/SSN
Name of clinic maintaining record
Name of mtf

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12
Q

Why would ancillary records be used?

A

Patient health information that is withheld from from their primary record

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13
Q

What are two examples of why an ancillary record would be used?

A

-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

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14
Q

Where would you place the stamp “secondary record” on a medical record used for ancillary reasons?

A

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”*

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15
Q

If transfer is necessary how can ancillary records be moved from one MTF to anther?

A

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

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16
Q

If ancillary record is not combined with primary record when it is closed, due to providers request, what will the medical record administrator do?

A

Retire it separately to the NPRC. The MRB must maintain a log that identifies when and where the record was retired.

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17
Q

Ancillary records can be viewed by what four people or groups?

A

Court of law
Patient review
Available to investigative bodies, NCIS
Protected from people outside of the law

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18
Q

When would medical records not need to be locked up?

A

If under a 24 hour watch

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19
Q

Medical Records are property of whom?

A

He US government

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20
Q

To avoid the frequent hand caring of records by patients the MTF were DTF should establish what systems?

A

Systems that allow delivery of records to clinics for scheduled appointments as well as The return back to the medical record department

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21
Q

What to system should be used to check medical and dental records out and in?

A

DEERS

CHCS

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22
Q

Who is responsible for the administration of the Navy’s medical records program?

A

BUMED patient admin division, medical records branch

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23
Q

Prepare what color EMF folder upon entry of an employee into the federal civil service?

A

Blue

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24
Q

When would an individual have two primary medical records?

A

If they were a federal civil service employee as well as a dependent or retiree

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25
Q

What happens if an active-duty member separation from service and continues to receive care regards to their medical record?

A

An OREC is made and documents are labeled, “duplicate record”

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26
Q

When are IRECs closed?

A

After the patient is discharged or transferred

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27
Q

What is the name for the medical record?

NAVMED

A

NAVMED 6150/10-19

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28
Q

How would you assign a pseudo-Social Security number for patients without socials?

A

800 for the first three digits

YY-MM-DD of DOB for the last 6

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29
Q

What happens if two patients with pseudo Ssn have the same DOB?

A

Use 801-899

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30
Q

What color MR and NAVMED number is used for patients with last two digits of their SSN are 00-09?

A

Orange

6150/10

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31
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 10-19?

A

Green

6150/11

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32
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 20-29?

A

Yellow

6150/12

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33
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 30-39?

A

Gray

6150/13

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34
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 40-49?

A

Tan

6150/14

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35
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 50-59?

A

Blue

6150/15

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36
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 60-69?

A

White

6150/16

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37
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 70-79?

A

Brown/almond

6150/17

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38
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 80-89?

A

Pink

6150/18

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39
Q

What color MR and NAVMED number is used for patients with lat two digits of their SSN are 90-99?

A

Red

6150/19

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40
Q

Which FMP is used for mother/step mother?

A

40-44

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41
Q

Which FMP is used for father/stepfather?

A

45-49

42
Q

Which FMP is used for mother in law?

A

50-54

43
Q

Which FMP is used for father in law?

A

55-59

44
Q

Which FMP is used for other authorized dependents?

A

60-69

45
Q

Which FMP is used for beneficiary authorized by statute?

Children of former service women, or dependent daughters

A

90-95

46
Q

Which FMP is used for civilian emergencies?

A

98

47
Q

Which FMP is used for all other?

A

99

48
Q

What and where must you right on an O-7 or above’s record?

A

Flag officer or general officer

Lower portion of the patients ID box

49
Q

What do you put In the alert box if patient does not have any allergies?

A

Nothing leave it blank

50
Q

For non-active-duty records how long after the last treatment will medical record be retired?

A

Two years after the calendar year date of last treatment

51
Q

Labels on medical records cannot be bigger than what size and should be place where on a medical record?

A

15/16 inches wide, 3 1/2 inches long

Lower right hand corner

52
Q

What format will be used to write dates on all documents in a medical record?

A

24JUN13

53
Q

What information may be overprinted on standard forms?

A

Permanent info

Mtf name address ect

54
Q

What information needs to accompany a HCPs signature?

A

Signers name
Grade
Profession or corps
SSN

55
Q

Civilian hospital forms are are approved for filing in medical records do not transcribe this information. What was the only exception of this rule?

A

HIV results

56
Q

Record positive HIV results on what four forms?

A

NAVMED 6000/2
NAVMED 6150/20
SF 601 imm rec
SF603 dental rec

57
Q

The nine digits of the SSN are divided into how many groups? What are they?

A

3

Primary, second, and third group

58
Q

Ex: 123-45-6789

In the above example which set of numbers are apart of the primary group?

A

89

59
Q

Ex: 123-45-6789

In the above example which set of numbers are apart of the second group?

A

67

60
Q

Ex: 123-45-6789

In the above example which set of numbers are apart of the third group?

A

123-45

61
Q

What is TDFS

A

Terminal digit filing system

How we file our records

62
Q

Facilities with fewer than 200 medical records may do what?

A

Put records in alphabetical order

63
Q

What are the two types of cross index files?

A

Patient index

Manuel systems

64
Q

What Must be done to medical record forms whenever they approach a state of illegibility or deterioration?

A

Duplicate

65
Q

Combine what three records no later than two working days before transfer to retirement?

A

Health record dental record and personnel record

66
Q

At a min what nine forms must be in a health record?

A 
NAVMED 6150/20.         SF 601
SF 545.                           OPNAV 5211/9
SF 88.                             SF 93
NAVMED 6150/4.           DD form 2005
SF 600
67
Q

Do NROTC candidate have health records?

A

Yes

68
Q

Inpatient:

The attending HP will ensure that major DX and TX associated with the patients stay will get documented on what form?

A

NAVMED 6150/20

69
Q

For patients who are UA for how many days you must send their HREC to PSD?

A

10 days

70
Q

Medical records are decided into what four parts?

A

1) record of preventative medicine and occupational health
2) record of medical care and treatment
3) physical qualifications
4) record of ancillary studies, inpatient care, and misc. forms

71
Q

What form is the immunization report and what section is it in?

(Not the 2766)

A

SF 601

Part 1

72
Q

What form is the chronological record of HIV testing?

A

NAVMED 6000/2

Part 1

73
Q

What form is the eyewear prescription and what section is it in?

A

DD 771

Part 1

74
Q

What form is the the MSQ and what part is it in?

A

OPNAV 5100/15

75
Q

What form is the progress note and what section would it be in?

A

SF 509

Part 2

76
Q

What form is the anesthesia?

A

SF 517

77
Q

What form is the anesthesia request?

A

SF 522

78
Q

What section do med board papers go?

A

3

79
Q

What form is the request for medical/ dental records? And what section does it go in?

A

DD 877

3

80
Q

What form is the privacy act and what section?

A

DD 2005

3

81
Q

What form is the rad consult?

A

SF 519 a/b

82
Q

What form is the lab reports?

A

SF 546-557

83
Q

How frequent must medical personnel verify HREC?

A

Annually

84
Q

How frequent will MTFs inventory their health records?

A

Yearly

85
Q

What form is the abstract of service and medical history?

A

NAVMED 6150/4

86
Q

What must medical personnel do to the medical record if someone is a deserter?

A
  • write a 600 and NAVMED 6150/4 explaining that the member is a deserter
  • deliver the HREC and dental to the CO

-if they get him the co has to request it from the CMC or BUPERS

87
Q

What must be done if a ADSM is convicted by civil authorities and discharged?

A

They need a physical either from a mtf or the penal institution

88
Q

What do you do to the HREC of someone who retires?

A

Make it a OREC

89
Q

What do you do to the HREC of a member who is terminal ill and is retired/retained?

A

Don t close HREC

Make a 600 to record date of retirement

90
Q

When will OREC of non active duty beneficiaries be verified?

A

When they check into an mtf and before retirement of the record

91
Q

When will OREC be retired?

A

Within 2 years of patient not receiving services, 5 for teaching services

92
Q

Who is the custodian of medical records on ship, deployable units?

A

Senior medical officer

93
Q

Where will medical records be kept when there are no medical personnel attached?

A

With service record

94
Q

Who must ensure that medical records are maintained?

A

Co

95
Q

How frequent must HREC be checked against pay list of ships roster to make sure all HREC are inboard for all members?

A

Quarterly

96
Q

What do you do to HREC during abandon ship?

A

Make necessary arrangements to salvage the HREC

97
Q

True or false:

HREC will accompany an active duty member when deployed

A

True

98
Q

What is multifaceted, multi-disciplinary program addressing all aspects of intervention related to maltreatment involving military personnel and their dependents?

A

FAP

Family advocacy program

99
Q

Commanding officers must appoint who to as the family as the family advocacy representative when the Number of new cases referred to the MTF case review subcommittee each month which is an average of eight for six consecutive months?

A

Full time social worker

100
Q

The commanding officer must hire a full time social worker when the number of new cases each month reaches an average of ___ for ___ consecutive months.

A

8

6

101
Q

What must be put in the HREC if a FAP is open?

A

On a SF 600 write, “FAP case record activated this date”

102
Q

What four laws has congress enacted which effect information in medical records?

A
  • Privacy act
  • FOIA
  • Drug abuse offense a d treatment act
  • Comprehensive alcohol abuse and alcoholism prevention and rehab act
103
Q

Privacy act of ____

A

1974

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