medical records navmed p-117 chapter 16 hm manual chapter 4
TRANSCRIPT
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Medical Records
NAVMED P-117 CHAPTER 16HM MANUAL CHAPTER 4
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3 MAJOR CATEGORIES
• HEALTH RECORD• OUTPATIENT RECORD• INPATIENT RECORD
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Secondary Medical Records
• Convenience
• Temporary
• Ancillary
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Ownership and Custody
• US Government• Commanding Officer• Minimize hand carrying by patient• Unauthorized individuals• CHCS tracking
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When/Where to open records
• HREC– Active enlisted member- medical RTC– Active officer- recruiting command
• OREC– 1st MTF
• IREC– Each admission
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NAVMED 6150-21/30
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NAVMED 6150-21/30
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FAMILY MEMBER PREFIX
XXXXXXXXXXXXXXXXX Spouse xxxxxxxxxxxxxxxxxxxxxx Spouse
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Terminal Digit Filing System
123-45-6789
• PRIMARY• SECONDARY• THIRD (TERTIARY)
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Special Categories
• Flight status• Radiation Exposure• “FLAG OFFICER”• “GENERAL OFFICER”
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NAVMED 6150/7
CHARGE OUT FORMHEALTH RECORD RECIEPT“PINK CARD”
USED WHEN COMPUTERTRACKING SYSTEM IS NOT EMPLOYED
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NAVMED 6150/20
• Summary of Care form• Top form on the left
side (side 1)
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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.
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SF 600/CHRONOLOGICAL RECORD OF MEDICAL CARE
• Sick call visit• Injuries
• SOAP notes• Record verification
• Drug allergies/hypersensitivity• Typed or handwritten
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DD 877
REQUEST FOR MEDICAL/DENTAL RECORDS
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DD 771 EYEWEAR PRESCRIPTION
3 CARBON COPY2 PART CARBONLESSCOMPUTER GENERATED
SHOULD BE TYPEWRITTENOR COMPUTERIZED WHENEVERPOSSIBLE TO AVOID ERRORSWHEN CREATING EYEWEAR
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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
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NAVMED 6600/3DENTAL HEALTH QUESTIONNAIRE
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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
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RECORD VERIFICATION
• ANNUALLY• REPORT• DETACH
• PHYSICAL EXAMS
• Make a SF 600 entry upon completion
• Black out corresponding year block
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HEALTH RECORD CLOSURE
•DEATH•DISCHARGE•RETIREMENT•DISENROLLMENT AS MIDSHIPMAN
INCLUDED FOR TRANSMITTAL WITH MEMBER’S SERVICE RECORD
FREE COPY TO MEMBER BY REQUEST
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• New OREC• Copy of HREC
• MTF sends copy of HREC to nearest VA for benefit processing
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LOST/DESTROYED/ILLEGIBLE
• REPLACEMENT
• DUPLICATE RECORD
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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
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Freedom of Information Act
• Public access to information • Deceased patients• Fees charged for released copies• SECNAVINST 5720.42 – DON FOIA Program
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WHAT IS THE DIFFERENCE BETWEEN A HREC AND
OREC?
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What color is my record if the last 4
of SSN is 4662?
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What is the FMP of my 3rd
husband?
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What is a DD 877?
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Name 2 ways to indicate a medical record verification
has been performed.
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