Record Keeping Flashcards
reasons for record keeping
required by law/regulations
only evidence of an effective HCP
critical for comparison
create medical/legal paper trail
characteristics of good records
consistent with OSHA/DoD/AF policies
accurate, thorough, organized, legible, attainable
created to protect health information
HIPPA
created by BE
lists hazards/controls
OEHED
where are OEHEDs filed
shop’s case file
member’s medical records
how long must noise exposure data be maintained
40 years
prepared by PH
list exposure levels + required medical exams
COHER
where are COHERs filed
member’s medical record
completed during initial reference audiogram and in event of PTS
AF Form 1753
cannot perform job
requested by provider
AF Form 1754 (fitness+risk)
used as comparison for future hearing tests
DD Form 2215
requirements for DD Form 2215 (reference audiogram)
14 hr noise free
no ENT problems
within 30 days of starting duty
used to document annual/periodic, termination, close scrutiny, pre/post deployment audiograms
DD Form 2216 (periodic audiogram)
requirements for DD Form 2216
NO noise free requirements
ENT problems are OK
same requirement for reference audiogram
designed to identify changes from baseline
follow-up tests
documented on DD Form 2217
daily biological calibration check
notify when a referral is required
DOEHRS-HC software
documents referrals
AF Form 1672
preferred form for documenting patient contact
SF 600 Overprint
notice sent to member/supervisor using
Memo for Record (MFR)
when should members be notified
within 21 days of confirmation of PTS
when should supervisors be notified
10 days after member is notified
all AD members separating or retiring from the AF will require a
Separation History and Physical Exam (SHPE)
percent of workers identified as noise exposed who were actually tested
compliance reports
available through DR
STS rate reports
high incidence of improved hearing on annual tests can indicate poor quality of reference audiograms
negative STS
more PTS than TTS indicated
follow-up tests are not being done
DOHERS offers you a wide array of reports that can be queried
completion reports
