CH4: Medical Records

Question 1

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

Answer 1

U.S. Navy Medical Outpatient and Dental Treatment Record

Question 2

What are the fundamentals of effective records’ management?

Answer 2

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

Question 3

Primary medical records are used for what documentation?

Answer 3

Outpatient and dental

Question 4

Secondary medical records are used for what documentation?

Answer 4

Specialty

Question 5

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

Answer 5

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

Question 6

What is filed under the Health (HREC)?

Answer 6

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

Question 7

Dental records file continuous care for?

Answer 7

AD, reserve, and their families

Question 8

What is filed under the Outpatient (OREC)?

Answer 8

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

Question 9

Where are summaries of inpatient (IREC) placed?

Answer 9

HREC (AD) or OREC (non-AD)

Question 10

What secondary records will not be opened for AD?

Answer 10

Temporary and ancillary

Question 11

Where are secondary records secured?

Answer 11

In a specialty clinic, separate from the primary record

Question 12

What is included in a secondary record?

Answer 12

Convenience, temporary, ancillary

Question 13

What does a convenience record contain?

Answer 13

Excerpts from the primary record

Question 14

What is the purpose of the temporary record?

Answer 14

An original record, documenting a current course of tx

Question 15

What must a temporary dental record contain?

Answer 15

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

Question 16

When are health and dental records opened?

Answer 16

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

Question 17

Are records opened for mustangs?

Answer 17

No, they use their existing HREC

Question 18

FMP for mother, stepmother?

Answer 18

40-44

Question 19

FMP for father, stepfather

Answer 19

45-49

Question 20

FMP for mother-in-law

Answer 20

50-54

Question 21

FMP for father-in-law

Answer 21

55-59

Question 22

FMP for Other Authorized Dependents

Answer 22

60-69

Question 23

FMP for All Other

Answer 23

99

Question 24

What information is in pencil on the inside front cover?

Answer 24

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

Question 25

Where is Part II of the medical record located?

Answer 25

Front of center page

Question 26

Where is the DD2005 Privacy Act Statement located?

Answer 26

In the front of the center page

Question 27

Where is the Disclosure Accounting Record?

Answer 27

On the back of the center page

Question 28

Where is the Forensic Examination form located?

Answer 28

Inside back cover

Question 29

Define primary number.

Answer 29

Last two numbers in SSN

Question 30

Define secondary number.

Answer 30

Second to last two numbers in SSN

Question 31

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

Answer 31

100

Question 32

What is the form number for orange?

Answer 32

NAVMED 6150/20

Question 33

What is the form number for red?

Answer 33

NAVMED 6150/29

Question 34

What is the form number for Health Record Receipt?

Answer 34

NAVMED 6150/7

Question 35

What form is also known as the pink card?

Answer 35

Health Record Receipt, NAVMED 6150/7

Question 36

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

Answer 36

Charge out guide

Question 37

What is a charge out guide?

Answer 37

A plastic folder with a pocket

Question 38

What is the charge out guide in place of?

Answer 38

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

Question 39

What is the DD form for Certificate of Death?

Answer 39

DD 2604

Question 40

What is DD 2604?

Answer 40

Certificate of Death

Question 41

What is the DD form for Narrative Summary?

Answer 41

SF 502

Question 42

What is SF 502?

Answer 42

Narrative Summary

Question 43

What is the DD form for Anesthesia?

Answer 43

SF 517

Question 44

What is SF 517?

Answer 44

Anesthesia

Question 45

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

Answer 45

SF 522

Question 46

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

Answer 46

SF 600

Question 47

When is a record closed?

Answer 47

- Death or declared death - Release from AD - Transfer to the Fleet Reserve or release to inactive duty

Question 48

Where do you record the closing entry?

Answer 48

NAVMED 6150/4, Abstract of Service and Medical History

Question 49

Where do you document desertion?

Answer 49

SF 600, EZ603A and NAVMED 6150/4

Question 50

How long do you retain loose forms?

Answer 50

1 year

Question 51

What instructions states the policy for loose forms?

Answer 51

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

Question 52

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

Answer 52

SF 600, in the HREC or OREC

Question 53

What form is preferred for imminent hospitalization?

Answer 53

SF 509 Medical Record-Progress Report

Question 54

What series is the Inpatient Data System?

Answer 54

BUMEDINST 6300.3

Question 55

Where are entries regarding hypersensitivity documented?

Answer 55

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

Question 56

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

Answer 56

Kept by the individual, personal record

Question 57

Where are imms recorded in the PHS-731 transcribed?

Answer 57

DD 2766

Question 58

What form is the consultation sheet?

Answer 58

SF 513

Question 59

What is SF 513?

Answer 59

Consultation sheet

Question 60

Define HQR.

Answer 60

Dental Health Questionnaire

Question 61

What is the most current Dental Treatment Form?

Answer 61

EZ603A

Question 62

Where are records retained?

Answer 62

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

Question 63

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

Answer 63

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