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IDC Unit 4 > 4.1 Military Treatment Records > Flashcards

4.1 Military Treatment Records Flashcards

1
Q

LIST the purposes of the military treatment record:

What is the purpose of the Military
Treatment Record?

A

Chronological record of medical treatment afforded members of the naval service.

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2
Q

LIST the purposes of the military treatment record:

The Medical Treatment Record has a current and long-term medico-legal value to who?

A

The individual concerned,

Their survivors,

U.S. Government.

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3
Q

LIST the purposes of the military treatment record:

Health Records (HRECs) are used to plan patient care and evaluate what?

A

The patient’s condition and treatment.

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4
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to furnish documentary evidence over the course of the patient’s?

A

Medical evaluation,

Treatment,

Change in condition.

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5
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to document communication between who?

A

Those who contribute to the patient’s care,

The practitioner responsible for the patient,

And all other health care professionals (HPs).

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6
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to
assist in protecting the legal interest of who?

A

The patient,

The Medical Treatment Facility (MTF),

Dental Treatment Facility (DTF),

The practitioner responsible for the patient,

The USN,

The U.S. Government.

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7
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to provide data for use in what?

A

Continuing education and research.

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8
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to justify costs incurred by who?

A

Third party payers.

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9
Q

Purposes of the military treatment record:

Health Records (HRECs) are used to serve as a vehicle of communication among who?

A

Health care providers,

Utilization management,

Risk management,

Quality assurance,

Medical records personnel,

Outside agencies.

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10
Q

Opening Military Treatment Records:

When is a new health record (HREC) opened?

A

Upon initial entry of a member into the Regular or Reserve naval service.

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11
Q

Opening Military Treatment Records:

Where can a new medical record be opened initially?

A

MEPS.

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12
Q

Opening Military Treatment Records:

A separate dental treatment record (DREC) is prepared when?

A

At the time of the first dental visit.

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13
Q

Opening Military Treatment Records:

For individuals who have had prior service and have been discharged,

Order their HREC and DREC from where?

A

The National Personnel Records Center.

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14
Q

LIST the occasions when the treatment record is opened and closed:

For individuals who have had prior service and have been discharged,

Order their HREC and DREC from the National Personnel Records Center using what form?

A

DD 877,

Request for Medical/ Dental Records.

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15
Q

LIST the occasions when the treatment record is opened and closed:

When a midshipmen or enlisted member is appointed to commissioned or warrant grade,

What happens to their existing HREC?

A

It will still be in use,

Make necessary entries to indicate new grade.

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16
Q

LIST the occasions when the treatment record is opened and closed:

When a midshipmen or enlisted member is appointed to commissioned or warrant grade,

Prepare Additional summary information entries on what forms?

A

SF 600 and NAVMED 6150/4.

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17
Q

Opening Military Treatment Records

Midshipmen/Enlisted Update:

What information is documented on SF 600 and NAVMED 6150/4?

A

Date,

Place,

Grade.

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18
Q

Closing Military Treatment Records:

When is a military health treatment record (HREC) closed?

A

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.

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19
Q

Closing Military Treatment Records:

When closing a medical record,

Record the closing entries on what form?

A

NAVMED 6150/4,

Abstract of Service and Medical History.

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20
Q

Closing Military Treatment Records:

When closing out a medical record,

What information needs to be included?

A

Date of separation,

Title of servicing activity,

Any explanatory circumstances.

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21
Q

Closing Military Treatment Records:

When closing a health record, the record needs to be organized and neat,

What are the ways to accomplish this?

A

In order,

No loose papers,

All identification data is consistent,

Ensure all pertinent documents are included.

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22
Q

Closing Military Treatment Records:

After closing the health record,

Deliver the entire health record, except as otherwise noted,

To where?

A

The command maintaining the member’s service record.

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23
Q

Closing Military Treatment Records:

How long do you have to deliver a medical record to the command after closing it?

A

No later than a day, following separation,

For inclusion in and transmittal with the member’s service record.

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24
Q

Closing Military Treatment Records:

If requested by a member, what are they are allowed a copy of?

A

Their health record (HREC).

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25
Q

Closing Military Treatment Records:

Ensure the separation physical examination’s original document and copy is included where?

A

In the HREC prior to delivery to the supporting command.

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26
Q

What record needs to be with the closed health record?

A

The dental record.

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27
Q

The medical record is the property of what?

A

The U.S. Government.

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28
Q

The medical record is the property of the U.S. Government and must be maintained by who?

A

The MTF or DTF,

Which has primary cognizance over the care of the patient.

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29
Q

Onboard ships,

The Senior Medical Department Representative (SMDR)/ Senior Medical Officer (SMO),

Has the custodial responsibilities of medical records by authority delegated from who?

A

The Commanding Officer.

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30
Q

When hospitalized at a Naval Military Facility (MTF),

What should be included with the inpatient record?

A

The HREC or OREC.

Includes transfer by aeromedical evacuation

If admitted to MTF away from station, forward HREC upon request.

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31
Q

When hospitalized and transferred to Federal Facilities,

The HREC will accompany who?

A

The patient,

Or send as soon as possible.

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32
Q

When members are transferred to Veterans Administration Medical Centers (VAMC),

Forward a copy of what?

A

The HREC,

All medical boards,

IREC of a patient,

Transfer the original HREC to the cognizant MTF.

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33
Q

When hospitalized at civilian medical facilities,

Be sure to forward what?

A

HREC to activity having administrative cognizance,

After confirming that the member’s length of stay warrants the transfer.

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34
Q

When hospitalized in foreign nations

Be sure to do what?

A

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.

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35
Q

Patients on UA in excess of 10 days,

Where do you send the record?

A

PSD,

Or

Unit holding member’s service/pay record.

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36
Q

When transferring a health record (HREC) to another duty station,

Be sure to verify what?

A

The HREC following MANMED Article 16-23(6),

Certify that the member has been processed for transfer.

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37
Q

Before transferring a medical record,

Be sure to include what?

A

The dental record.

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38
Q

Members may hand carry their HREC per which instruction?

A

BUMEDNOTE 6150.

39
Q

Complete the full medical record charge out,

Following which instruction?

A

MANMED Article 16-37(11).

40
Q

With a medical record check out,

Be sure to fill out what?

A

NAVMED 6150/7.

41
Q

What is NAVMED 6150/7?

A

Charge out Receipt Card,

“Pink Card.”

42
Q

What information is filled out on NAVMED 6150/7?

A

Note the new duty station,

And file in alphabetical index for forwarding any remaining health care chits/forms.

43
Q

The NAVMED 6150/7 is maintained for how long?

A

It shall be maintained for one year after the date of transfer.

44
Q

If applicable, a SAMS transfer disk is also placed in what during a transfer?

A

The HREC.

45
Q

In the event the member’s HREC has been lost or is otherwise unaccounted for, an administrative remarks entry is made where?

A

NAVPERS 1070/613.

46
Q

Documenting the circumstances, shall be made in the service record prior to what?

A

Transfer.

47
Q

When a health treatment record is lost or destroyed, the cognizant custodian is responsible for what?

A

Opening a new “REPLACEMENT” health treatment record,

In accordance with Article 16-23 of the MANMED, Chapter 16.

48
Q

With a lost or destroyed medical record,

The designation “REPLACEMENT” shall be prominently entered where?

A

On the jacket and all forms replaced.

49
Q

With a lost or destroyed medical record,

A synopsis of the circumstances requiring the replacement and the date accomplished shall be set forth on what form?

A

The replacement SF-600.

50
Q

If the missing record is subsequently recovered,

The additional information or entries contained in the replacement record shall be inserted where?

A

In the original record.

Do not maintain replacement copies after locating the primary record.

51
Q

A health treatment record or any portion thereof shall be duplicated whenever it approaches a state of what?

A

Illegibility or deterioration,

Which may possibly endanger future use or value as a permanent record.

52
Q

The duplicate health treatment record or portion shall be a reproduction of what?

A

The originals as much as possible,

Particular attention to detail shall be employed in actual transcription.

53
Q

Prominently enter the designation “DUPLICATE RECORD” on the front of the file folder above what?

A

TREATMENT RECORD,

When the entire contents of a medical record is duplicated.

54
Q

When only a part of the medical record is duplicated, identify the individual forms how?

A

Write “DUPLICATE” at the bottom of each form.

55
Q

The circumstances necessitating duplication and date accomplished shall be set forth on what form?

A

SF 600.

56
Q

Microfiche all forms replaced by duplicate forms in what?

A

An envelope for protection and preservation,

Make the envelope a permanent part of the medical record.

57
Q

If microfilming capability is not available to the MTF,

The original forms (except contaminated) will be placed inside what?

A

A plain envelope for protection and preservation,

Made a permanent part of the medical record.

58
Q

If microfilming capability is not available to the MTF, the original forms (except contaminated) will be placed inside a plain envelope for protection and preservation and made a permanent part of the medical record,

On the front of this envelope, record the identifying data required by what?

A

Article 16-13.

59
Q

Mark the envelope how?

A

Original Medical Records,

Permanent,

File at the bottom form on the right side of the medical record jacket.

60
Q

What filing system do we use for medical records?

A

The terminal digit filing system,

TDFS.

61
Q

The terminal digit filing system is used to file records according to what?

A

Terminal digit,

Color-coded,

Blocked filing system.

62
Q

Guidelines on the TDFS, are further outlined where?

A

Article 16-18, of the MANMED, CH. 16.

63
Q

The health record shall be verified to insure all required entries are present in the record when?

A

Upon receipt or check-in,

At the time of physical examination,

Before transfer.

64
Q

The Medical Department having custody of the record shall verify records at what periodicity?

A

Annually,

An appropriate entry shall be made on the SF 600.

65
Q

During a medical record verification, when do you update the year of verification?

A

Mark through the current year after the verification is complete.

66
Q

Inside of the health record jacket in section 1,

Record information on the inside of the jacket using what?

A

Pencil,

Keep updated at all times.

67
Q

The NAVMED 6150/7, Health Record Receipt “Pink Card,”

May be used for what?

A

Charge out control of records,

This form is maintained in the health record until record is checked out.

68
Q

What is the minimum data that shall be recorded on each charge out form?

A

Family member’s prefix code and SSN,

Member’s name,

Name of ship/station.

69
Q

When the record is checked out,

What needs to be filled out on the pink card?

A

Date,

Received By,

and/or,

Location.

70
Q

The completed charge out form shall be maintained until when?

A

The record is returned.

71
Q

Signatures in the record must be what?

A

Identifiable.

72
Q

Signatures in the record,

Local guidance dictates the form and content, but what needs to be included at the minimum?

A

The signer’s name,

Grade,

Profession or corps,

Last four of SSN.

73
Q

Signatures in the record,

In signing, the individual assumes responsibility for what?

A

The correctness of the entry.

74
Q

Correction to Entries,

May be made by who?

A

Personnel authorized to document in the medical record,

Preferably by the person who made the original entry.

75
Q

Correction to Entries,

How do you correct an entry?

A

Draw a single line through the information that is in error and initial.

76
Q

Correction to Entries,

The one lined information must remain what?

A

Readable.

77
Q

Correction to Entries,

The information must remain readable,

Since deletion, obliteration, or destruction of medical record information is not what?

A

Authorized,

Except through proper channels,

Outlined in Articles 16-39, 16-40, and 16-41 of MANMED

78
Q

Correction to Entries,

After the one line, what do you need to add?

A

The new information,

Date,

Sign with full identification,

Per section III.

79
Q

Correction to Entries,

If helpful, an explanation of why the corrected entry was made may be what?

A

Written.

80
Q

Documentation of Visits,

Dates?

A

A complete date must be on every page of the medical record.

This is true even for forms which are back to front.

81
Q

Documentations of visits,

Use what abbreviation?

A

The three-letter abbreviation for the month on all dates,

13 Nov 94.

82
Q

Documentation of Visits,

For each visit enter the name of the patient’s what?

A

MTF Name,

Name of hospital,

Ship,

Clinic,

Unit.

83
Q

Documentation of Visits,

For each visit enter the name of the patient’s what?

A

Clinic department or service,

Health Care Provider’s (HCP’s) name,

Grade or rate,

Profession,

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.

84
Q

Establish a HREC, containing at a minimum, the forms delineated in what instruction?

A

Article 16-23 of the MANMED, Ch. 16.

85
Q

Where are the four places you document an allergy in the medical record?

A

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)

86
Q

Hypersensitivity/Allergy to a drug, chemical, anesthetic or requires prophylactics prior to receiving what?

A

Dental treatment due to congenital heart disease.

87
Q

Hypersensitivity/Allergy to a drug, chemical, anesthetic or requires prophylactics prior to receiving dental treatment due to congenital heart disease,

Enter in red across the top of what forms?

A

EZ 603/603A.

88
Q

How do you fill out a DD 877?

A

Requesting activity shall complete Items 1 through 10 (except 8b), and item 19,

The addressee shall complete Items 8b, 11 to 14 or 15 to 18, as appropriate, final referrer shall return to requester.

89
Q

Purposes of a medical warning tag:

To recognize special health problems when what?

A

Medical records are not available,

Patient is unable to give medical history.

90
Q

Dental Class 1 (White)?

A

Individuals having no pathological oral conditions and requiring no treatment.

91
Q

Class 2 (Green)?

A

Individuals with minor pathological oral conditions for which early clinical treatment is indicated.

92
Q

Class 3 (Yellow)?

A

Individuals with pathological oral conditions for which early clinical treatment is indicated.

93
Q

Class 4 (Red)?

A

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.

IDC Unit 4 (11 decks)

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