Unit 4.1 Medical Records Flashcards
LIST the purposes of the military treatment record
- 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
LIST the occasions when the treatment record is opened
- 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
LIST reasons for Closing Military Treatment Records
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
NAVMED 6150/4
Abstract of Service and Medical History
DD 877
Request for Medical/ Dental Records
custodial responsibilities for the military treatment records
- 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
Hospitalization at civilian medical facilities:
Forward HREC to activity having administrative cognizance, after confirming that the member’s length of stay warrants the transfer
Members transferred to Veterans Administration Medical Centers (VAMC):
Forward a copy of the HREC, all medical boards, and IREC of a patient
Transfer the original HREC to the cognizant MTF
Admission to hospital in foreign nation:
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
Hospitalization at Naval Military Facility (MTF):
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
Hospitalization and transfer to Federal Facilities:
HREC will accompany patient, or send as soon as possible
DECRIBE the disposition procedures for the military treatment records in the event of unauthorized absence
Patients on UA in excess of 10 days, send the record to PSD or unit holding member’s service/pay record
DECRIBE the disposition procedures for the military treatment records in the event of transfer to another duty station
- 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
Lost or Destroyed Health Records
- 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
LIST the actions to be taken on military treatment records if destroyed
- 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
Filing Records
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
When to Complete Record Verification
Upon receipt (check-in) At the time of physical examination Before transfer Annually **documented on SF 600
steps of record verification
- 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
Charge Out Control
NAVMED 6150/7, Health Record Receipt “Pink Card,” may be used for charge out control of records
Minimum data recorded on charge out form
- Member’s family member’s prefix code and SSN
- Member’s name
- Name of ship/station
Describe Correction to Entries
- 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
Documentation of Visits (Entries for Medical Conditions)
- 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
DD 2766
Adult Preventive and Chronic Care Flow sheet
NAVMED 6230/4 (replaced SF 601),
Immunization Record
NAVMED 6000/2
Chronological Record of HIV Testing
DD 771
Eye Wear Prescription
NAVMED 6470/10
Record of Occupational Exposure to Ionizing Radiation
SF 558
Medical Record-Emergency Care and Treatment Record
SF 600
Chronological Record of Medical Care
DD 2215
Reference Audiogram
DD 2216
Hearing Conservation Data
OPNAV 5100/15
Medical Surveillance Questionnaire
NAVMED 1300/1
Medical, Dental, and Educational Suitability Screening for Service and Family Members
NAVMED 1300/2
Medical, Dental, and Educational Suitability Screening for Service and Family Members Checklist and Worksheet
NAVPERS 1300/16
Report of Suitability for Overseas Assignment Parts I, II, and III
DD 2808
Report of Medical Examination, Replaced SF 88
DD 2807-1
Report of Medical History, Replaced SF 93
DD 877
Request for Medical/Dental Records
LIST the entries required for hypersensitivity and medical conditions in the military treatment records
- 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)
Use of DD Form 877
Request for Medical/ Dental Records
STATE the purposes of a medical warning tag
To recognize special health problems when:
- –Medical records are not available
- –Patient is unable to give medical history
Dental class 1
Deployable, Individuals having no pathological oral conditions and requiring no treatment
Dental class 2
Deployable, Individuals with minor pathological oral conditions for which early clinical treatment is indicated
Dental class 3
non-deployable, Individuals with pathological oral conditions for which early clinical treatment is indicated
Dental class 4
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
