Navy and Marine Corps personnel and DoD eligible beneficiaries utilize what U.S. Navy Medical Outpatient and Dental Treatment Record as the official record jacket for the chronological documentation of medical and dental evaluations, care, treatments, and occupatinal health?
NAVMED 6150/21-30
What medical records are used for the documentation of outpatient medical and dental care?
Primary
What is a file of continuous care given to active duty members and documents all outpatient care provided during a member’s career?
HREC
What containes all documents of dental care provided during a member’s career?
DREC
What is a file of continuous care that documents ambulatory treatment recieved by a person other than an active duty person, I.e. retiree and family memebers?
OREC
What is a medical file that documents care provided to a patient assigned to a designated inpatient bed at an MTF or ship?
IREC
Opening a secondary medical record requires the healthcare provider to write a note on the Adult Preventive and Chronic CAre Flow Sheet which is what form in the primary treatment record?
DD form 2766
What record contains excerpts from a patient’s primary record and is kept within the MTF by a treating clinic, service, department, or individual provider for increased access to the information?
Convenience
What records consist of original healthcare documentation withheld from a patients primary HREC or OREC?
Ancillary
The Navy Medical Department uses what system to file health records?
Terminal Digit Filing System (TDFS)
Under the Terminal Digit Filing System, the central files are divided into how many approximately equal sections?
100
What charge out Form Health Record Receipt also known as the pink card, will be used for charge out control of medical records?
NAVMED 6150/7
What charged out from the file should be returned as soon as possible after the patient’s visit, but not more than how many working days?
5
When open-shelf filing is used for records, what may be used in conjunction with the charge out form?
Charge out guide
All records are verified how often by medical and dental personnel having custody of them?
Annually
Upon completion of an annual medical record verification, the HM will make an entry on the what for medical records and black-out the corresponding year block on the front leaf of the jacket with a black felt tip pen?
SF 600
Upon final discharge or death, send the complete and verified health and dental records to the command maintaining the member’s service record (no later than how long following separation) for inclusionin and transmittal with the member’s service record?
1 day
When loose treatment forms are discovered, every effort should be made to determine the present location of the record. If reasonable search efforts do not locate the record, retain loose forms for a period of how long?
1 year
Porperly maintained, what form aids healthcare providers by allowing them quick access to pertinent medical factors that may affect how they manage a patient’s medical care?
DD Form 2766
The DD Form 2766 is divided into how many pages?
4
What provides a continuous comprehensive record of a patient’s medical history?
SF 600
What form is routinely used for inpatient admission notes and is filed in the patient’s IREC?
SF 509
When a member of the navl service incurs an injury that might result in permanent disability or results in a physical inability to perform duty for a period exceeding how many hours, an entry will be made concerning line- of - duty misconduct?
24
The specific protocol for recording anthrax immunizations is outlined in what series?
SECNAVINST 6230.4
When recording positive results (how many mm or more induration) of the tuberculin skin test (TST) refer to BUMEDINST 6224.8 series Tuberculosis Control Program, for guidance?
10
Any immunizations recorded on the PHS-731 should be transcribed onto the what?
DD form 2766
Accoring to international rules, entries on the PHS- 731 require authentication for immunizations against smallpox (if administered), yellow fever, cholera, and what else?
Anthrax
What form is initiated when military personnel are first exposed to ionizing radiation (with the exception of patients incurring such radiation while undergoing diagnostic treatment)?
DD Form 1141
What form is used to summarize clinical data relative to treatment recieved during periods of hospitalization?
SF 502
The SF 539 may be used as a substitute for the narrative summary for those admissions of a minor nature that require less than how many hours of hospitalization?
48
What is used for outpatients who need to be reffered to other healthcare providers or specialists, such as gynecologists, internists, optometrists, etc?
SF 513
What form is used to order corrective prescription eyewear?
DD Form 771
Who is the official responsible for administering and supervising the execution of SECNAVINST 5211.5 series, Department of the Navy Privacy Act Program (PAP), as it pertains to the Health Care Treatment Record System?
Surgeon General of the Navy
