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e-5 advancement > CH4: Medical Records > Flashcards

CH4: Medical Records Flashcards

1
Q

What is the official record jacket for Navy and Marine Corps personnel and DOD eligible?

A

U.S. Navy Medical Outpatient and Dental Treatment Record

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2
Q

What are the fundamentals of effective records’ management?

A

Opening, filing, verifying, and closing AD and reserve medical and dental records

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3
Q

Primary medical records are used for what documentation?

A

Outpatient and dental

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4
Q

Secondary medical records are used for what documentation?

A

Specialty

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5
Q

What are the 3 major categories of a primary medical record?

A

Health (HREC), Outpatient (OREC), Inpatient (IREC)

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6
Q

What is filed under the Health (HREC)?

A

Continuous care given to active duty, documents all outpatient care provided during a member’s career

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7
Q

Dental records file continuous care for?

A

AD, reserve, and their families

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8
Q

What is filed under the Outpatient (OREC)?

A

Ambulatory tx for someone other than AD (ie. retiree and family)

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9
Q

Where are summaries of inpatient (IREC) placed?

A

HREC (AD) or OREC (non-AD)

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10
Q

What secondary records will not be opened for AD?

A

Temporary and ancillary

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11
Q

Where are secondary records secured?

A

In a specialty clinic, separate from the primary record

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12
Q

What is included in a secondary record?

A

Convenience, temporary, ancillary

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13
Q

What does a convenience record contain?

A

Excerpts from the primary record

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14
Q

What is the purpose of the temporary record?

A

An original record, documenting a current course of tx

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15
Q

What must a temporary dental record contain?

A

Privacy Act Statement, DD 2005, Dental Health Questionnaire (NAVMED 6600/3), Dental Treatment Form (EZ603A)

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16
Q

When are health and dental records opened?

A

Becoming AD, retired and returned to AD, original lost/destroyed

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17
Q

Are records opened for mustangs?

A

No, they use their existing HREC

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18
Q

FMP for mother, stepmother?

A

40-44

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19
Q

FMP for father, stepfather

A

45-49

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20
Q

FMP for mother-in-law

A

50-54

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21
Q

FMP for father-in-law

A

55-59

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22
Q

FMP for Other Authorized Dependents

A

60-69

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23
Q

FMP for All Other

A

99

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24
Q

What information is in pencil on the inside front cover?

A
  1. Date of arrival
  2. PRD
  3. Address and number
  4. UIC and number
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25
Q

Where is Part II of the medical record located?

A

Front of center page

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26
Q

Where is the DD2005 Privacy Act Statement located?

A

In the front of the center page

27
Q

Where is the Disclosure Accounting Record?

A

On the back of the center page

28
Q

Where is the Forensic Examination form located?

A

Inside back cover

29
Q

Define primary number.

A

Last two numbers in SSN

30
Q

Define secondary number.

A

Second to last two numbers in SSN

31
Q

Under the terminal digit filing system, central files are divided into how many equal sections?

A

100

32
Q

What is the form number for orange?

A

NAVMED 6150/20

33
Q

What is the form number for red?

A

NAVMED 6150/29

34
Q

What is the form number for Health Record Receipt?

A

NAVMED 6150/7

35
Q

What form is also known as the pink card?

A

Health Record Receipt, NAVMED 6150/7

36
Q

What can be used in conjunction with the charge out form?

A

Charge out guide

37
Q

What is a charge out guide?

A

A plastic folder with a pocket

38
Q

What is the charge out guide in place of?

A

In place of the patient’s record until the record is returned

39
Q

What is the DD form for Certificate of Death?

A

DD 2604

40
Q

What is DD 2604?

A

Certificate of Death

41
Q

What is the DD form for Narrative Summary?

A

SF 502

42
Q

What is SF 502?

A

Narrative Summary

43
Q

What is the DD form for Anesthesia?

A

SF 517

44
Q

What is SF 517?

A

Anesthesia

45
Q

What is the DD form for Request for Administration of Anesthesia?

A

SF 522

46
Q

Where does the HM make an entry for an annual medical record verification?

A

SF 600

47
Q

When is a record closed?

A
  • Death or declared death
  • Release from AD
  • Transfer to the Fleet Reserve or release to inactive duty
48
Q

Where do you record the closing entry?

A

NAVMED 6150/4, Abstract of Service and Medical History

49
Q

Where do you document desertion?

A

SF 600, EZ603A and NAVMED 6150/4

50
Q

How long do you retain loose forms?

A

1 year

51
Q

What instructions states the policy for loose forms?

A

Paragraph six, SECNAVINST 5212.5 series Navy and Marine Corps Records Disposition Manual

52
Q

What form is used for all outpatient care and where is it placed?

A

SF 600, in the HREC or OREC

53
Q

What form is preferred for imminent hospitalization?

A

SF 509 Medical Record-Progress Report

54
Q

What series is the Inpatient Data System?

A

BUMEDINST 6300.3

55
Q

Where are entries regarding hypersensitivity documented?

A

SF 601 (IMM record), EZ603A (Dental Treatment Report), NAVMED 6150/10-19 (jackets), DD 2766 (Adult Preventive and Chronic Care Flow Sheet)

56
Q

Where are international certificates of vaccination (PHS-731) kept?

A

Kept by the individual, personal record

57
Q

Where are imms recorded in the PHS-731 transcribed?

A

DD 2766

58
Q

What form is the consultation sheet?

A

SF 513

59
Q

What is SF 513?

A

Consultation sheet

60
Q

Define HQR.

A

Dental Health Questionnaire

61
Q

What is the most current Dental Treatment Form?

A

EZ603A

62
Q

Where are records retained?

A

In the custody of the MO or DO to which the member is assigned

63
Q

What is the procedure is a member is hospitalized in a foreign nation?

A

Entry made in HREC, HREC retained on board and continued until the patient returns to duty.

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