Medical Records

NAVMED P-117 CHAPTER 16HM MANUAL CHAPTER 4

3 MAJOR CATEGORIES

• HEALTH RECORD• OUTPATIENT RECORD• INPATIENT RECORD

Secondary Medical Records

• Convenience

• Temporary

• Ancillary

Ownership and Custody

• US Government• Commanding Officer• Minimize hand carrying by patient• Unauthorized individuals• CHCS tracking

When/Where to open records

• HREC– Active enlisted member- medical RTC– Active officer- recruiting command

• OREC– 1st MTF

• IREC– Each admission

NAVMED 6150-21/30

NAVMED 6150-21/30

FAMILY MEMBER PREFIX

XXXXXXXXXXXXXXXXX Spouse xxxxxxxxxxxxxxxxxxxxxx Spouse

Terminal Digit Filing System

123-45-6789

• PRIMARY• SECONDARY• THIRD (TERTIARY)

Special Categories

• Flight status• Radiation Exposure• “FLAG OFFICER”• “GENERAL OFFICER”

NAVMED 6150/7

CHARGE OUT FORMHEALTH RECORD RECIEPT“PINK CARD”

USED WHEN COMPUTERTRACKING SYSTEM IS NOT EMPLOYED

NAVMED 6150/20

• Summary of Care form• Top form on the left

side (side 1)

DD 2766

•ADULT PREVENTITIVE AND CHRONIC CARE FLOW SHEET

•4 Pages

•Summary of problems, medications, imms, lab tests, etc.

•Updated during each visit, annually, and upon transfer.

SF 600/CHRONOLOGICAL RECORD OF MEDICAL CARE

• Sick call visit• Injuries

• SOAP notes• Record verification

• Drug allergies/hypersensitivity• Typed or handwritten

DD 877

REQUEST FOR MEDICAL/DENTAL RECORDS

DD 771 EYEWEAR PRESCRIPTION

3 CARBON COPY2 PART CARBONLESSCOMPUTER GENERATED

SHOULD BE TYPEWRITTENOR COMPUTERIZED WHENEVERPOSSIBLE TO AVOID ERRORSWHEN CREATING EYEWEAR

PHS-731INTERNATIONAL CERTIFICATES OF

VACCINATION

•Kept by the individual for independent travel•NOT TO BE FILED IN THE HREC•Authentication stamps • YF• Cholera• Smallpox• Anthrax

NAVMED 6600/3DENTAL HEALTH QUESTIONNAIRE

MISC FORMS

• SF 601- IMMUNIZATION RECORD• DD 2215- REFERENCE AUDIOGRAM• DD 2216- HEARING CONSERVATION DATA• DD 2807- REPORT OF MEDICAL HISTORY• DD 2808- REPORT OF MED EXAMINATION• SF 519- RADIOGRAPHIC REPORTS• SF 545- LABORATORY REPORT DISPLAY

RECORD VERIFICATION

• ANNUALLY• REPORT• DETACH

• PHYSICAL EXAMS

• Make a SF 600 entry upon completion

• Black out corresponding year block

HEALTH RECORD CLOSURE

•DEATH•DISCHARGE•RETIREMENT•DISENROLLMENT AS MIDSHIPMAN

INCLUDED FOR TRANSMITTAL WITH MEMBER’S SERVICE RECORD

FREE COPY TO MEMBER BY REQUEST

• New OREC• Copy of HREC

• MTF sends copy of HREC to nearest VA for benefit processing

LOST/DESTROYED/ILLEGIBLE

• REPLACEMENT

• DUPLICATE RECORD

PRIVACY ACT 1974

• Law relates to release of patient information to themselves or their legal

representation

• Released to their physician if deemed appropriate

• DD 2005

Freedom of Information Act

• Public access to information • Deceased patients• Fees charged for released copies• SECNAVINST 5720.42 – DON FOIA Program

WHAT IS THE DIFFERENCE BETWEEN A HREC AND

OREC?

What color is my record if the last 4

of SSN is 4662?

What is the FMP of my 3rd

husband?

What is a DD 877?

Name 2 ways to indicate a medical record verification

has been performed.