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Surface Force IDC > Unit 4.1 Medical Records > Flashcards

Unit 4.1 Medical Records Flashcards

1
Q

LIST the purposes of the military treatment record

A
  • plan patient care and evaluate patients condition
  • furnish documentary evidence of patients care
  • document communication
  • assist legal interest of all parties
  • provide research data
  • justify costs
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2
Q

LIST the occasions when the treatment record is opened

A
  • OPENED
    • upon initial entry into service, MEPS
    • For individuals who have had prior service and have been discharged, DD877
    • When a midshipmen or enlisted member is appointed to commissioned or warrant grade, the existing HREC shall be continued in use.
    • Make necessary entries to indicate new grade.

*Additionally prepare summary information entries on SF 600 and NAVMED 6150/4 to include date, place, and grade to which appointed

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3
Q

LIST reasons for Closing Military Treatment Records

A

In accordance with Article 23 of the MANMED Chapter 16, a military health treatment record (HREC) shall be closed when a member:

  • Dies/declared dead
  • Is discharged
  • Resigns (Officers ONLY)
  • Is released from active duty
  • Retires
  • Is transferred to the Fleet Reserve and released to inactive duty
  • Is declared missing or missing in action
  • Is declared a deserter
  • Is dis-enrolled from officer candidate or midshipman programs

*Record the closing entries on NAVMED 6150/4, Abstract of Service and Medical History

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4
Q

NAVMED 6150/4

A

Abstract of Service and Medical History

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5
Q

DD 877

A

Request for Medical/ Dental Records

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6
Q

custodial responsibilities for the military treatment records

A
  • The medical record is the property of the U.S. Government and must be maintained by the MTF or DTF, which has primary cognizance over the care of the patient
  • Onboard ships, the Senior Medical Department Representative (SMDR)/ Senior Medical Officer (SMO) has the custodial responsibilities by authority delegated from the Commanding Officer
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7
Q

Hospitalization at civilian medical facilities:

A

Forward HREC to activity having administrative cognizance, after confirming that the member’s length of stay warrants the transfer

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8
Q

Members transferred to Veterans Administration Medical Centers (VAMC):

A

Forward a copy of the HREC, all medical boards, and IREC of a patient
Transfer the original HREC to the cognizant MTF

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9
Q

Admission to hospital in foreign nation:

A

Make entry of that fact in HREC
Send HREC to MTF having administrative cognizance
If applicable, place English translation of the narrative summary in the HREC

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10
Q

Hospitalization at Naval Military Facility (MTF):

A

Include the HREC or OREC and copy of IREC with the patient
Includes transfer by aeromedical evacuation
If admitted to MTF away from station, forward HREC upon request

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11
Q

Hospitalization and transfer to Federal Facilities:

A

HREC will accompany patient, or send as soon as possible

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12
Q

DECRIBE the disposition procedures for the military treatment records in the event of unauthorized absence

A

Patients on UA in excess of 10 days, send the record to PSD or unit holding member’s service/pay record

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13
Q

DECRIBE the disposition procedures for the military treatment records in the event of transfer to another duty station

A
  • Verify the HREC following MANMED Article 16-23(6) and certify that the member has been processed for transfer
  • Include the dental record before transfer
  • Member may hand carry HREC per BUMEDNOTE 6150
  • Complete medical record charge out following MANMED Article 16-37(11)
  • Fill out NAVMED 6150/7, Charge out Receipt Card “Pink Card,” and note new duty station and file in alphabetical index for forwarding any remaining health care chits/forms
  • This record of transfer shall be maintained for one year after the date of transfer.
  • If applicable, a SAMS transfer disk is also placed in the HREC
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14
Q

Lost or Destroyed Health Records

A
  • an administrative remarks (NAVPERS 1070/613) entry, documenting the circumstances, shall be made in the service record prior to transfer (chain of Command)
  • the cognizant custodian is responsible for opening a new “REPLACEMENT” health treatment record in accordance with Article 16-23 of the MANMED, Chapter 16
  • –Designation of REPLACEMENT prominently entered on the jacket and all forms replaced.
  • If found and additional information transferred to original
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15
Q

LIST the actions to be taken on military treatment records if destroyed

A
  • Prominently enter the designation “DUPLICATE RECORD”
  • When only a part of the medical record is duplicated, identify the individual forms as “DUPLICATE” at the bottom of each form
  • document reason and date of duplication on SF 600
  • Microfiche all forms replaced by duplicate forms in an envelope for protection and preservation and make the envelope a permanent part of the medical record
  • — On front of this envelope, record the identifying data required by Article 16-13
  • — Mark the envelope Original Medical Records – Permanent and file as the bottom form on the right side of the medical record jacket
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16
Q

Filing Records

A

The terminal digit filing system (TDFS) is used to file records according to a terminal digit, color-coded, and blocked filing system
** Guidelines are further outlined in Article 16-18, of the MANMED, CH. 16

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17
Q

When to Complete Record Verification

A 
Upon receipt (check-in) 
At the time of physical examination 
Before transfer 
Annually
**documented on SF 600
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18
Q

steps of record verification

A
  • Mark through the current year after verification is complete.
  • Inside of the health record jacket front leaf:
  • —Record information on the inside of the jacket front leaf in pencil
  • —Keep updated at all times
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19
Q

Charge Out Control

A

NAVMED 6150/7, Health Record Receipt “Pink Card,” may be used for charge out control of records

20
Q

Minimum data recorded on charge out form

A
  • Member’s family member’s prefix code and SSN
  • Member’s name
  • Name of ship/station
21
Q

Describe Correction to Entries

A
  • draw a single line through the information that is in error and initial
  • Add the new information, date, and sign with full identification per section III
22
Q

Documentation of Visits (Entries for Medical Conditions)

A
  • Date: A complete date must be on every page of the medical record. This is true even for forms which are back to front, using the three-letter abbreviation for the month on all dates, e.g., 13 Nov 94
  • MTF Name: Name of hospital, ship, clinic, or unit
  • Clinic department or service
  • Health Care Provider’s (HCP’s) name, grade or rate, profession and last four of SSN
  • Chief complaint or purpose of visit and subjective history
  • Objective findings
  • Diagnosis or medical impression.
  • Studies ordered and results, such as laboratory or x-ray studies.
  • Therapies administered.
  • Disposition, recommendations, and instructions to patient.
  • Signatures or initials of practitioners
23
Q

DD 2766

A

Adult Preventive and Chronic Care Flow sheet

24
Q

NAVMED 6230/4 (replaced SF 601),

A

Immunization Record

25
Q

NAVMED 6000/2

A

Chronological Record of HIV Testing

26
Q

DD 771

A

Eye Wear Prescription

27
Q

NAVMED 6470/10

A

Record of Occupational Exposure to Ionizing Radiation

28
Q

SF 558

A

Medical Record-Emergency Care and Treatment Record

29
Q

SF 600

A

Chronological Record of Medical Care

30
Q

DD 2215

A

Reference Audiogram

31
Q

DD 2216

A

Hearing Conservation Data

32
Q

OPNAV 5100/15

A

Medical Surveillance Questionnaire

33
Q

NAVMED 1300/1

A

Medical, Dental, and Educational Suitability Screening for Service and Family Members

34
Q

NAVMED 1300/2

A

Medical, Dental, and Educational Suitability Screening for Service and Family Members Checklist and Worksheet

35
Q

NAVPERS 1300/16

A

Report of Suitability for Overseas Assignment Parts I, II, and III

36
Q

DD 2808

A

Report of Medical Examination, Replaced SF 88

37
Q

DD 2807-1

A

Report of Medical History, Replaced SF 93

38
Q

DD 877

A

Request for Medical/Dental Records

39
Q

LIST the entries required for hypersensitivity and medical conditions in the military treatment records

A
  • NAVMED 6230/4, Immunization Record under Remarks and Recommendations
  • DD 2766, block 1
  • Placing an “X” on the front leaf of the health/dental record in the alert box
  • SF 600, Chronological Record of Medical Care (patient acknowledgement of hypersensitivity and reaction & medical warning tags)
40
Q

Use of DD Form 877

A

Request for Medical/ Dental Records

41
Q

STATE the purposes of a medical warning tag

A

To recognize special health problems when:

  • –Medical records are not available
  • –Patient is unable to give medical history
42
Q

Dental class 1

A

Deployable, Individuals having no pathological oral conditions and requiring no treatment

43
Q

Dental class 2

A

Deployable, Individuals with minor pathological oral conditions for which early clinical treatment is indicated

44
Q

Dental class 3

A

non-deployable, Individuals with pathological oral conditions for which early clinical treatment is indicated

45
Q

Dental class 4

A

non-deployable, Individuals whose classification is unknown because they have not received an oral examination by a Dental Officer within the past 12 months or for whom no dental record exists

Surface Force IDC (26 decks)

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