Purpose Of Health Record Maintenace Flashcards
What is the purpose of a medical record paper or electronic?
To provide an individual chronological record of medical treatment afforded members of naval service.
What is one of the most important aspects of healthcare administration?
The appropriate documentation and disposition of healthcare information.
How is most Healthcare information recorded?
Electronic medical record(EMR)
Primary medical records are mostly used for what?
The documentation of outpatient medical and dental care.
What are the three major categories of primary medical records.
Health record outpatient record and dental records
Where are summaries of inpatient care placed?
HREC (Active duty) or OREC ( non active duty personnel) to maintain continuity of care.
Who establishes a patients secondary medical record?
Specialty healthcare provider
Secondary medical records contain what kind of information?
Medical info needed by that provider for a specific need.
Secondary medical records are maintained ? From the primary medical record.
Separate
What is required for a secondary medical record to be opened?
Healthcare provider to write a note on the DD form 2766 Adult preventative and chronic care flowsheet in the primary treatment record
Convenience records contains ?
Excerpts from a patients primary record and is kept within the MTF by a treating clinic, service,department, or individual provider for increased access to the information
What are temporary records.
An original medical record established and retained in a specialty clinic service or department in addition to the patient’s primary medical record.
What is the purpose of a temporary record?
Document a current course of treatment
When does a temporary medical record become a part of the primary medical record?
When the course of treatment is concluded
Where is temporary records most Commonly used or established?
OB/GYN for prenatal patient
The temporary dental record is maintained by who?
The DTF providing the current course of treatment
When can a patient help carry their temporary dental record?
When treatment is complete or when the patient returns to the location of the permanent dental record
If a patient does not hand carry their temporary dental record, Who is responsible for that records do what must they do with the record?
Custodian of the temporary record was forwarded to the custodian of the permanent record
The temporary dental record must contain a minimum of which forms?
Privacy act statement DD 2005, Dental health questionnaire, and dental treatment form.
What do ancillary records consist of?
Original healthcare documentation withheld from a patient’s primary HREC or 0REC.
Examples- spouse abuse
All treatment records are the property of whom?
US government
Who has the ultimate responsibility for all medical records?
CO Commanding officer
What three medical records are patients not authorized to retain or maintain?
Original HREC, 0REC, or dental record.
The handling of all medical records must be in accordance with what two laws?
Privacy act of 1974 and HIPPA protocol.
When medical department personnel or not assigned the seal make a sign custody of the health records to whom ?
Local medical and dental department.
Can an individual hold on to the medical record?
It’s never permitted
When our health and dental records opened?
When an individual becomes a member of the Navy or Marine corp
Retiree return to active duty
Original record has been lost or destroyed
When establishing the four part health record the appropriate health record jacket required forms must be what?
Current and assembled in accordance with current directives.
Who opens active duty officers health records? And after it’s opened where is the health record sent?
Recruiting command open HRECS for civilian applicants who are excepted for an officer appointment. Health record forwarded to new officers first duty station.
Who opens an active duty enlisted personnel health record(HREC)? What’s the exception to this rule?
Open by the activity executing The original enlistment contract in the Navy or Marine corp. An exception to this rule involves service members who are enlisted or inducted in order to immediate active duty at recruit training facility
When is a new U.S. Navy medical outpatient and dental record prepared? And what happens to the old jacket?
Hint O.D.
Record is opened or existing jacket has been damaged or deteriorating to the point of illegibility. Old jacket destroyed.
A felt or permanent black marker will be used to record all identifying data except in the?
Pencil Entries block
Where is the pencil entries block?
Hint -upper and outer
On the upper left of the outer front cover of these medical records. Should be written in pencil
Each health record has the______ to last digit of the social security number preprinted on it, the preprinted digit also matches the________ digit of the form number.
Second; Last
The color of the treatment( record) corresponds to the ?
Preprinted digit which is the second digit of your social security’s number
The preprinted digit also matches the ________ digit of the form number
Last
In preparing a a treatment record jacket what do you do.
Select a pre-numbered jacket by matching the second to the last number of the members SSN.
Where do you enter the rest of the members ssn?
The top inside back cover ( part 6)
For members who do not have a ssn (Foreign military personnel) use what numbered treatment record?
Nine
For foreign military personnel, what last 4 digits of an substitute SSN are assigned to them? And how are the first five digits assigned ?
9999; the first 5 digits in a number sequence
Example 000-01-9999 first ssn 000-02-9999
What should be placed over the number that corresponds to the last digit of the SSN in each of the two number scales on the inside back cover of The HREC( health record).
Black cellophane tape
Where on the treatment do you entered the families prefix(FMP) code?
In the two diamonds preceding the SSN on the top of part 6
Where do you enter the member’s ( patient) full name? And if the patient doesn’t have a middle name what do you write in the space?
Hint upper and outside
Upper right corner of the outside front cover of the treatment
NMN- no middle name
Where is the alert box located?
Hint lower and outside
Lower center area of the outside cover
If a member (patient) has drug allergies or drug sensitivities how is that recorded on the treatment jacket? If the patient has no allergies
Enter an X in the appropriate box
Leave it blank
If a patient allergies or drug sensitives are listed ensure that all information is on what other documents?
DREC( dental)
HREC(active duty)
OREC(non-active duty)
How do you indicate a records category ?
Hint outside front
Entering an X in the appropriate box on the outside front cover below pencil entries.
What indicates an active duty treatment record?
1/2 inch red cellophane tape to the record category block on the right edge of the inside back cover of the jacket.
What’s below the record category area?
Patient service and status box, and special category
What’s listed below record category type?
Special categories
How do you identify if the patient is an flag officer or general officer?
Stamping Or printing flag officer or general officer on the lower portion of the patient identification box.
Where is the retired year tape box located?
Inside back cover
What does the barcode label indicate?
hint F.S.R.R-V
FMP, SSN, record type, record volume number.
Where should the barcode label be placed?
The front of the record jacket in the box to the right of the alert box.
What happens if the barcode is a part of the patient identification label?
Place this level in the patient identification box
What should be written on the inside front cover of the record jacket and written in what and why?
Hint D.P.H-T.C&T
Information should be written in pencil so it can be updated easily
Date of arrival, projected rotation date, home address and telephone number, command UIC and telephone number.
What goes on the front of center page of record jacket?
Imprint of DD 2005 privacy act statement. Must be signed and dated in black ink by the patient, however, if a minor must be signed by a parent or guardian
What goes on the back of the center page?
disclosure accounting record
What goes on the inside back cover of the record jacket And should be Completed if the record is going to be use for what?
Forensic Examination form; dental care.
What system does the Navy medical department use to file health records?
Terminal digit filing system (TDFS)
Records are filed according to terminal digitsWhich or what?
Hint SSN , color, block
Last two numbers of the servicemember Social Security number, color coding of the record jacket, and use of block filing system.
Why are the nine digits of the Social Security number divided into three number groups?
Reduce the chance of transposing numbers
Using the TDFS system how is the Social Security number grouped and read?
Right to left
What is the FMP which is family member prefixFor active duty personnel? What would it be for a spouse and what would it be for a child?
20;30;01
Primary number?
Last two numbers of SSN
SeCondary numbers?
Two number in front of the last two number of SSN
Third number?
First 5 digits of SSN
When a record is charged out how long can the record be out before it Has to be returned to treatment records?
Not more than 5 working days
NavMEd 6150/7 health record receipt is also known as the?
Pink card used to take out medical records, shore based commands have An electronic record charge out system
What should be recorded on each health record receipt when treatment record is received?
Hint P.S.P.S
Patients name sponsor grade or rate, patients FMP code and sponsors SSN, ship or station to which sponsor is assigned
How often are records verified?
Annually(yearly)
When are health records reviewed?
When servicemembers report and detach from their commands and physical examinations.
During verification of records HREC & DREC what items are reviewed?
Form placement, order of forms (chronological), completeness and accuracy of patient identification data on the record jacket and on each piece of medical documentation, privacy act statement has been signed, DD2766 is updated as necessary, operational and occupational requirements updated,Currency of immunizations, allergy documentation are complete
Upon completion of an annual medical record verification the HM will make an entry on the? For medical records and black out the corresponding year block on the? Of the jacket with a black felt tip pen.
SF600;front leaf
Where is the annual verification section located?
Right hand side of the front cover of record jacket
Why might a members health records be closed?
Death, discharge, resignation, released from active duty, retirement, transfer to the fleet reserve or release to in active duty, missing or missing in action, desertion, and disenrollment as an officer candidate or midshipmen.
Where do you record the closing entry? And what information do you record?
NAVMED6150/4 abstract of service and medical history
Date of separation, title of servicing activityAnd any explanatory circumstances
When you combine members health dental and personal records before transfer or retirement to the command maintaining the service record how long do you have before those records need to be transferred?
Two working days
Healthcare providers will enter their signature and identification data in the HREC in only what two colors of ink?What goes below the healthcare provider signature? Can stamped facsimile signatures be used in an HREC?
Black or blue
Name, grade or reading and social security number
No
All forms documenting patient care and filed in records will at a minimum contain the following data in the identification block what information is placed in that block?
Patients FMP and sponsors SSN
Patients name
Sponsors branch of service
What three methods are currently used to place patient identification on medical documents?
Embossed medical cards
Automated forms
Handwritten entries
What happens when a HRECO or OREC is lost or destroyed?
The custodian will open a replacement record. Replacement written on front of record. Forms and record replaced. Explanation as to why the record was replaced.Date when they created a replacement record will be entered in the SF 600 chronological record of medical care. If the original record is found all of the forms from the replacement record will be placed in the original record.
When should the HREC or 0REC be duplicated?
When it’s legible or deteriorates
When duplicating an entire health record place what word properly on the front of the jacket above the wording outpatient medical record?
Duplicate record
When duplicating only part of a record or only certain healthcare medical forms what should be printed at the bottom of every form?
Duplicate
How long do you hold on to lose treatment forms?
One year
When assembling a medical record arrange the forms of the same type in chronological order by date what documents should be at the top and what documents should be at the bottom?
The most current document should be placed on the top and the least current documents be placed on the bottom
The HREC and 0REC record divide into four parts what are the four parts of these records?
Part one record of preventative medicine and occupational health
Part two record of medical care and treatment
Part three physical qualifications
Part for record of ancillary studies,Inpatient care, and miscellaneous forms.
The adult preventative and chronic care flowsheet DD2766 contains a summation Of what?
Relevant problems and medications that significantly affect the patient’s health status
The DD form 2766 is divided into four pages what are the four pages?
Significant health problems, hospitalization and surgery, medical alert and medications, health maintenance
What kind of information does the SF 600 provide?
Continuous comprehensive record of a patient’s medical history
Entries on the SF 600 Are mostly made in what?
If the rest or back page of Sf 600 is not used what should Be written on the back
Handwritten Black or blue ink pens;No further entries in the middle of the page
What information can you find in an SF 600?
Complains ,duration of illness,Injury, physical findings, clinical course, results of laboratory and etc.
Should do you record each visit and complaint described even if a member is return to duty without treatment?
Yes Document if a patient leaves before being seen
Filed in part two of the medical record other SF 600 entries Include the following?
Imminent hospitalization Special procedures and therapy Sick call visits Injuries or poisonings Line of duty inquiries Binnacle list and sick list Reservist check in and check on statements
When a patient’s admission imminent Admission notes can be made on SF 600 however which form is preferred?
SF509 medical record progress report
What’s a narrative summary(SF502)
Summarized clinical data relative to treatment received during periods of hospitalization mismatch nav/med 6300–5
What’s A consultation sheet SF 513?
It is used for our patients who need to be referred to other healthcare provider or specialist such as gynecologist for example
What are the three dental record forms used?
NavMEd 6600/3 dental Questionnaire
Dental exam forms
Current dental treatment form
