Presentation on theme: "Medical Records NAVMED P-117 CHAPTER 16 HM MANUAL CHAPTER 4."— Presentation transcript:
Medical Records NAVMED P-117 CHAPTER 16 HM 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 – 1 st MTF IREC – Each admission
FAMILY MEMBER PREFIX XXXXXXXXXXXXXXXXX Spouse xxxxxxxxxxxxxxxxxxxxxx Spouse
Terminal Digit Filing System PRIMARY SECONDARY THIRD (TERTIARY)
Special Categories Flight status Radiation Exposure “FLAG OFFICER” “GENERAL OFFICER”
NAVMED 6150/7 CHARGE OUT FORM HEALTH RECORD RECIEPT “PINK CARD” USED WHEN COMPUTER TRACKING 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 COPY 2 PART CARBONLESS COMPUTER GENERATED SHOULD BE TYPEWRITTEN OR COMPUTERIZED WHENEVER POSSIBLE TO AVOID ERRORS WHEN CREATING EYEWEAR
PHS-731 INTERNATIONAL CERTIFICATES OF VACCINATION Kept by the individual for independent travel NOT TO BE FILED IN THE HREC Authentication stamps YF Cholera Smallpox Anthrax
NAVMED 6600/3 DENTAL HEALTH QUESTIONNAIRE
MISC FORMS SF 601- IMMUNIZATION RECORD DD REFERENCE AUDIOGRAM DD HEARING CONSERVATION DATA DD REPORT OF MEDICAL HISTORY DD 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 – 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 3 rd husband?
What is a DD 877 ?
Name 2 ways to indicate a medical record verification has been performed.