HM Chapter 04: Medical Records Flashcards
(113 cards)
0
Q
What are the medical records named?
A
NAVMED 6150/20-29
1
Q
How many category of records are there?
A
3: health, outpatient, inpatient
2
Q
Temporary records are also known as
A
Ancillary records
3
Q
Who has ultimate responsibility for medical records?
A
Commanding Officer
4
Q
Pencil entries are made….
A
In the first section of medical record in upper left corner; includes command & rank
5
Q
01-19 is
A
Dependent Child
6
Q
12 is …
A
Activated reserve
7
Q
20-29 is …
A
Active Duty
8
Q
30-39 is
A
Dependent spouse/former spouse
9
Q
40-44 is …
A
Dependent Mother or Stepmother
10
Q
45-49 is …
A
Dependent father or stepfather
11
Q
50-54 is …
A
Dependent mother in law
12
Q
55-59 is …
A
Dependent father in law
13
Q
60-69 is …
A
Other authorized dependents
14
Q
98 is …
A
Civilian employees
15
Q
99 is …
A
All others
16
Q
Preparing the medical record includes 3 parts, which are…
A
Part 1: done in pencil
Part 2: Signed DD 2005 (privacy act) in pen
Part 3: Disclosure Accounting Record
17
Q
What’s the name if the navy’s medical record filing system?
A
Terminal Digit Filing System
18
Q
NAVMED 6150/20
A
Orange
19
Q
NAVMED 6150/21
A
Green
20
Q
NAVMED 6150/22
A
Yellow
21
Q
NAVMED 6150/23
A
Gray
22
Q
NAVMED 6150/24
A
Tan
23
Q
NAVMED 6150/25
A
Blue
24
NAVMED 6150/26
White
25
NAVMED 6150/27
Almond
26
NAVMED 6150/28
Pink
27
NAVMED 6159/29
Pink
28
NAVMED 6150/7
Health Record Receipt (pink card)
29
What to do for foreign medical records?
Enter 00; also NMN is notated on front cover to indicate no middle name.
30
Located in part 1 of medical record?
Record of Preventive & Occupational Health
31
Located in part 2 of medical record
Record of medical care & treatment
32
Located in Part 3 of medical record
Physical qualifications
33
Located in part 4 of medical records
Record of ancillary studies, inpatient care, lab reports, miscellaneous forms
34
NAVMED 6150
Summary of Care form (always on top)
35
SF 601
Immunization Record
36
NAVMED 6000/2
Chronological record of HIV testing
37
DD 771
Eyewear prescription
38
NAVMED 6490/1
Visual record
39
NAVMED 6470/10
Occupational exposure to radiation
40
NAVMED 6470/11
Exposure to radiation from internal radionuclide
41
DD 2215
Reference audiogram
42
NAVMED 6260/5
Asbestos medical surveillance program
43
DD 2216
Annual hearing conservation data
44
DD2493-1
Asbestos Exposure - Part 1 initial & Part 2 periodic
45
OPVAV 5100/15
Medical Surveillance Questionnaire
46
NAVPERS 5510/1
Record identifier for Personnel Reliability Program (PRP)
47
SF 588
Emergency care & treatment/ ambulance care
48
SF 600
Chronological record of care
49
SF 513
Medical record consultation sheet
50
DD 2161
Referral for civilian medical care
51
DD 2064
Death Certificate
52
SF 503
Autopsy protocol
53
SF 523
Authorization for autopsy
54
SF 523A
Disposition of body
55
SF 523B
Authorization for tissue donation
56
NAVMED 6300/5
Inpatient admission disposition record
57
SF 502
Narrative Summary
58
SF 539
Abbreviation Medical Record
59
SF 509
Progress Notes
60
SF 516
Operation Report
61
SF 517
Anesthesia Report
62
SF 522
Request for Anesthesia
63
DD 602
Patient Evaluation Tag
64
NAVMED 1300/1
Medical & Dental overseas screening review for active duty and dependents
65
NAVPERS 1300/16
Report of suitability of overseas screening
66
NAVMED 6100/1
Medical board report cover sheet
67
NAVMED 6100/2
Medical board statement of patient
68
NAVMED 6100/3
Medical board certificate
69
NAVMED 6100/5
Abbreviated Medical Evaluation Board Report
70
DD 2807
Medical History
71
DD 2808
Medical Examination
72
DD 2697 is
Report of Medical Assessment
73
NAVPERS 1745/1
Exceptional Family Member program application
74
DD 2569
Third Party Collection Program
75
OPNAV 5211/9
Record of Disclosure (Privacy Act of 1974)
76
DD 877
Request for Medical & Dental records
77
SF 515
Tissue Examination
78
SF 519
Medical record radiographic reports
79
SF 508
Blood or blood competent transfusion
80
SF 545
Laboratory report display
81
SF 511
Vital Signs Record
82
SF 512
Plotting chart
83
SF 233
Prenatal and pregnancy civilian medical care notes
84
SF 2824C
Physician statement for employee disability retirement
85
SF 47
Physical fitness inquiry for motor vehicle operators
86
SF 78
Certificate of medical examination
87
What does DNA stand for
Deoxyribonucleic Acid
88
NAVMED 6120/2
Officer physical examination special questionnaire
89
NAVMED 6120/3
Annual certificate physical condition
90
NAVMED 6150/4
Abstract of Service and medical history
91
SF 217
Epilepsy medical report
92
SF 518
Blood or Blood component transfusion
93
SF 520
Electrocardiogram request
94
SF 524
Radiation Therapy
95
SF 525
Radiation Therapy summary
96
SF 526
Intestinal/ inter-cavity therapy
97
SF 527
Group muscle strength
98
SF 53
Neurological Exam
99
SF 531
Anatomical figure
100
SF 541
Gynecologic cytology
101
SF 560
Electroencephalogram request & history.
102
PHS 731
International Certificates of vaccination; a personal record of immunizations that is not filled in HREC
103
Dental record part 1 includes
Radiographs
104
Dental record part 2 includes
NAVMED 6600/3 (dental health questionnaire)
105
Dental record part 3 includes
Dental exam forms, EZ 603 (dental examination report)
106
Dental record part 4 includes
Current dental status form, EZ 603A (dental treatment record)
107
How often are records verified by medical?
Annually
108
On what occasions are records reviewed?
Reporting, detachment , and all physical exams
109
How are records sent if they can't be hand carried during PCS
Send via certified mail with copy of DD 877
110
How to close a medical record?
Ensure data is consistent and in chronological order and record closing entry with pertinent info on page 4 (NAVMED 6150/4: abstract of service & medical)
111
How to report MIA members?
Document circumstances of presumed disappearance on SF 600
112
How to report deserters?
Document on SF 600, EZ 603 and page 4; deliver record to CO
