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32 Cards in this Set

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  • Back
What are the 3 categories of medical records?
Hrec includes DREC, ORECS includes DRECS, and IRecs
ORECS are for?
ORECS are for?

Non- active, family membersSecondary Medical records are for?
Temp active duty records are for only OB?GYN, fam adovocacy, psychology and psyc clinical records.
Secondary Medical records are for?
Temp. active duty records for only OB?GYN, fam adovocacy, psychology and psyc clinical records.
Are secondary recs part of the primary? What guidlines establishe the instruction?
NO, MANMED
To open a secondary record what is needed?
requires the healthcare provider to write a note on the DD form 2766, adult preventive med and chronic care flow sheet in the primary treatment record.
What is a NAVMED 6150/21-30?
US Navy Medical Outpatient and Dental record.
What treatment record is used for members who do not have a SSN?
NAVMED 6150/29 as the TX record jacket.
When opening a new record what must be included?
DD2807 Report of medical history and a DD2808 Report of medical examination
What is a DD2807?
Report of medical History
What is a DD2808?
Report of medical exam.
What are is the prefix for children?
(01-19)-xxx-xx-xxx
Prefix for a spouse?
30/xxx-xx-xxx
Mother, Stepmother prefix?
40-44
Father, Stepfather Prefix?
45-49
Mother in law prefix?
50-54
Father in law prefix?
55-59
Other authorized dependent?
60-69
Benificiary authorized by statue?
90-96
Civilian emergencies?
98
all others prefixes for records?
99
all others prefixes for records?
Summary of care/ imms
what is kept in part II of the medical record?
Chronological documentation of care
What is kept in part III of the med rec?
Overseas screening, boards, physical exams, exposure forms ( Asbestos, radiatiion, etc)
What is kept in part IV of the medcal record?
Labs, xrays, EKG, ancillary studies.
What are the rec color for 00-50?
Orange, 2green, 3yellow, 4grey, 5Tan.
What are the rec color for 06-99
What are the rec color for 06-99
06white, 07almond, 08pink, 09red.
What is a 6150/7?
a Charge out form. a pink card.
What are the year blocks on the Med REcs used for?
Annual record verification. Blacked out when completed. must also complete an SF600
How are annual verification documented on a dental rec?
On the EZ603A during the time of the annual exam. no need to blacken out the year.
When constructing a new dental record, what first must be done.
A t-2 Exam.
When HREC and DREC cannot be carried, how is it sent?
Via Certified mail. With a DD Form 877, Request for medical and dental record.
When closing a MEDREC for discharge, where should this be documented?
NAVMED 6150/4 Abstract of Service and Medical History.