Flashcards in BN3 Records Deck (71):
What term means arranged according to the order of time?
What is a continuous file of dental care and treatment given to active duty and reserve members and their families?
What term describes a number that designates sponsorship?
Family Member Prefix (FMP)
What term describes a file of continuous care given to an active duty member and documents all outpatient care provided during a member's career?
Health Record (HREC)
What term describes a medical file which documents care provided to a patient assigned to a designated inpatient bed in a medical treatment facility (MTF) or ship?
Inpatient Health Record (IREC)
What term describes a file of continuous care which documents ambulatory received by a person other than an active duty member?
Outpatient Record (OREC)
what color record would a "0" be?
what color record would "1" be?
what color record would "2" be?
what color record would "3" be?
what color record would "4" be?
what color record would "5" be?
what color record would "6" be?
what color record would "7" be?
what color record would "8" be?
what color record would "9" be?
what is the family member prefix for sponsor?
what is the family member prefix for spouse?
what is the family member prefix for second spouse?
what is the family member prefix for second child?
what is the family member prefix for first child?
what is the family member prefix for foreign military?
What are the four parts of the health record
Part 1: Record of preventive medicine and occupational health. Part 2: Chronological record of medical care and treatment. Part 3: Physical qualifications, physical profiles and exposures forms. Part 4: Record of Ancillary Studies and miscellaneous forms
What forms contain a record of prophylactic immunizations and contains information concerning hypersensitivities and allergies?
What form is the chronological record of HIV testing?
What form is the baseline audiogram?
What form would you find a record of a member's medical history (e.g sickcall) that is filed in chronological order with the most recent on top?
What form would you find a record of care given in an emergency situation? This form is interfiled with the SF600s
What form would be used to summarize clinical data relative to treatment received during periods of hospitalization?
What from is a medical record continuation?
What from is a progress note?
What form is used to refer a patient to a specialist for detailed exam and/or procedure?
What form is used to document and inform members of their privacy rights?
DD Form 2005
Where are SF 513s filed?
immediately above the SF 600 or SF 558 containing the last entry prior to date of SF513
What form is a Line of Duty Determination?
AF Form 348
What form is a record of Inpatient treatment?
What AF form is the summary of care?
What form is the Abstract of Service and Medical Hx?
What form is the third Party Collection Party form?
What form is the Record of Disclosure?
What form is the request for medical/dental record information?
When is the DD877 used?
to request medical/dental records.
Used when permanently transferring medial and dental records to another facility
What form is the pre-deployment health assessment?
What form is the post deployment health assessment?
What form is the Post deployment health re-assessment?
What form is the report of Medical Examination?
DD2808 or SF88
What form is the Report of Medical History?
DD2807 or SF93
what AF form is the Physical Profile Serial Report?
AF form 422
What form is the Laboratory Report Display?
What form is the Radiologic consultation requests/reports?
What form is lab results?
What does part 1 of the dental record contain?
What form is the dental health questionnaire?
Where in the dental records is the NAVMED 6600/3(dental health questionnaire) located?
What form is used for most dental exams and is not used for emergencies?
Where is the EZ603 located in the dental record?
What form documents the most current dental treatment and what section is it located in?
EZ603A in Part 4
How are EZ603As and SF603s filed?
Reverse chronological order
What Inpatient form provides a summary of patient's health history to identify actual and potential nursing care problems?
NAVMED 6550/14(Patient data base)
What inpatient form provides a summary of inpatient data and treatment received during hospitalization?
SF 502 (Narrative Summary)
What inpatient form is used to record a course of current hospitalization, including signs and symptoms, duration of complaints and the circumstances of admission?
SF504 (history part 1)
What inpatient form records occupation, military history, lifetime injuries and illnesses, as well as drug sensitivities and allergies?
SF505 (History Part 2&3)
What inpatient form is a record of physical examinations, including the patient's physical and mental characteristics?
SF506 (Physical Exam)
What inpatient form provides written instructions by the physician, directing the medical care and treatment of the patient?
SF 508(Doctor's orders)
What inpatient form is used by physicians to record a patient's response to treatment?
SF509 (Progress note)
*Other medical personnel may use this form to record comments (dietitian, anesthetist)
What inpatient form is used for observations, patients progress, treatments and some medications are recorded by the nurses and corpsman/technicians?
SF510 (Nursing Notes)
What inpatient form is used to standardize treatment and provide a ready reference for care given to a patient?
NAVMED 6550/12 (Patient Profile) or Air Force Inpatient Flowchart
What inpatient form is a record of temperature, pulse, blood pressure, respirations, height and weight as well as intake and output?
SF 511 (Vital Signs Record)
What inpatient form is used to record all medications administered during a seven day time period?
NAVMED 6550/8 Medication Administration record
What form is used to accurately document a patient's actual fluid intake and output (I&O) over a twenty-four hour period?
DD 792 (Twenty-Four Hour Intake and Output worksheet)