Record Keeping Flashcards

(28 cards)

1
Q

reasons for record keeping

A

required by law/regulations
only evidence of an effective HCP
critical for comparison
create medical/legal paper trail

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2
Q

characteristics of good records

A

consistent with OSHA/DoD/AF policies
accurate, thorough, organized, legible, attainable

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3
Q

created to protect health information

A

HIPPA

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4
Q

created by BE
lists hazards/controls

A

OEHED

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5
Q

where are OEHEDs filed

A

shop’s case file
member’s medical records

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6
Q

how long must noise exposure data be maintained

A

40 years

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7
Q

prepared by PH
list exposure levels + required medical exams

A

COHER

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8
Q

where are COHERs filed

A

member’s medical record

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9
Q

completed during initial reference audiogram and in event of PTS

A

AF Form 1753

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10
Q

cannot perform job
requested by provider

A

AF Form 1754 (fitness+risk)

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11
Q

used as comparison for future hearing tests

A

DD Form 2215

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12
Q

requirements for DD Form 2215 (reference audiogram)

A

14 hr noise free
no ENT problems
within 30 days of starting duty

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13
Q

used to document annual/periodic, termination, close scrutiny, pre/post deployment audiograms

A

DD Form 2216 (periodic audiogram)

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14
Q

requirements for DD Form 2216

A

NO noise free requirements
ENT problems are OK

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15
Q

same requirement for reference audiogram
designed to identify changes from baseline

A

follow-up tests

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16
Q

documented on DD Form 2217

A

daily biological calibration check

17
Q

notify when a referral is required

A

DOEHRS-HC software

18
Q

documents referrals

19
Q

preferred form for documenting patient contact

A

SF 600 Overprint

20
Q

notice sent to member/supervisor using

A

Memo for Record (MFR)

21
Q

when should members be notified

A

within 21 days of confirmation of PTS

22
Q

when should supervisors be notified

A

10 days after member is notified

23
Q

all AD members separating or retiring from the AF will require a

A

Separation History and Physical Exam (SHPE)

24
Q

percent of workers identified as noise exposed who were actually tested

A

compliance reports

25
available through DR
STS rate reports
26
high incidence of improved hearing on annual tests can indicate poor quality of reference audiograms
negative STS
27
more PTS than TTS indicated
follow-up tests are not being done
28
DOHERS offers you a wide array of reports that can be queried
completion reports