Hm 04 Medical Record

Front 1

Opening a secondary medical record requires the healthcare provider to write a note on the ____ in the primary treatment record.

Back 1

DD Form 2766, Adult Preventive and Chronic Care Flow Sheet

Front 2

For Navy and Marine Corps service members who were discharged before 31 January 1994, requests should be sent to the _____ for record retrieval.

Back 2

National Personnel Records Center (NPRC)

Front 3

For service members who were discharged after 31 January 1994, requests for record retrieval are sent to the _____.

Back 3

Department of Veterans Affairs (VA).

Front 4

FMP 00

Back 4

All foreign military personnel

Front 5

FMP 20

Back 5

Sponsor

Front 6

FMP 01-19

Back 6

Children

Front 7

First child FMP
Second child FMP
...

Back 7

01
02
...

Front 8

FMP 30

Back 8

1st Spouse

Front 9

First spouse FMP
Second spouse FMP
...

Back 9

30
31
...

Front 10

FMP 40-44

Back 10

Mother, Stepmother

Front 11

FMP 45-49

Back 11

Father, Stepfather

Front 12

FMP 50-54

Back 12

Mother-in-law

Front 13

FMP 55-59

Back 13

Father-in-law

Front 14

FMP 60-69

Back 14

Other Authorized Dependents

Front 15

FMP 90-95

Back 15

Beneficiary Authorized by Statute
法规授权受益人

Front 16

FMP 98

Back 16

Civilian Emergencies

Front 17

FMP 99

Back 17

All Others

Front 18

FMP for retirees

Back 18

20

Front 19

Identify flag officers and general officers by stamping or printing ___ or ___ as appropriate, on the lower portion of the patient identification box.

Back 19

“FLAG OFFICER” or "GENERAL OFFICER,"

Front 20

Medical Record Jacket

Back 20

NAVMED 6150/10-19

Front 21

Dental Record Jacket

Back 21

NAVMED 6150/21-30

Front 22

NAVMED 6150/10 color

Back 22

Orange

Front 23

NAVMED 6150/11 color

Back 23

Green

Front 24

NAVMED 6150/12 color

Back 24

Yellow

Front 25

NAVMED 6150/13 color

Back 25

Grey

Front 26

NAVMED 6150/14 color

Back 26

Tan

Front 27

NAVMED 6150/15 color

Back 27

Blue

Front 28

NAVMED 6150/16 color

Back 28

White

Front 29

NAVMED 6150/17 color

Back 29

Almond/Brown

Front 30

NAVMED 6150/18 color

Back 30

Pink

Front 31

NAVMED 6150/19 color

Back 31

Red

Front 32

DENTAL CLASSIFICATION TAPE: Blue

Back 32

Active duty

Front 33

DENTAL CLASSIFICATION TAPE: Red

Back 33

Reserves

Front 34

DENTAL CLASSIFICATION TAPE: yellow

Back 34

Family members

Front 35

DENTAL CLASSIFICATION TAPE: Green

Back 35

Retired

Front 36

DENTAL CLASSIFICATION TAPE: black

Back 36

All others

Front 37

Part I (Inside front cover): ____

Back 37

Record of Preventive Medicine and Occupational Health

Front 38

Part II Section A: ____

Back 38

Record of Medical Care and Treatment

Front 39

Part II Top Forms: ____

Back 39

Forms After a Patient is Deceased

Front 40

Part II: Section B: ____

Back 40

Inpatient Care, Ambulatory Surgeries, etc.

Front 41

Part III (Back of Center Page): ____

Back 41

Physical Qualifications

Front 42

Part IV (Inside of Back Cover): ___

Back 42

Record of Ancillary Studies, Inpatient Care, and miscellaneous forms

Front 43

During PCS, if the medical and dental records are not to be hand carried, forward them via certified mail along with a ____ or place medical and dental records in the custody of authorized personnel.

Back 43

DD Form 877, Request for Medical/Dental Records Information

Front 44

The specific protocol for recording anthrax immunizations is outlined in ____.

Back 44

SECNAVINST 6230.4 series, Department of the Navy (DoN) Anthrax Vaccination Implementation Program (AVIP).

Front 45

When a member is officially declared a deserter, document the event fact on the ___, ___ and ___.

Back 45

SF 600, EZ603A and the NAVMED 6150/4

Front 46

Upon request of the retiring member, a new medical record (OREC) is established. Dental records should be verified and retired at the same time, and forwarded to the National Personnel Records Center, Military Personnel Records, _____.

Back 46

St. Louis, Missouri

Front 47

Healthcare providers will enter their signature and identification data in the HREC in _____ ink.

Back 47

black or blue-black

Front 48

The ____ is not to be filed in the HREC at any time. Any immunizations recorded on the this form should be transcribed onto the _____.

Back 48

PHS-731
DD Form 2766 (Adult preventive and chronic care flowsheet).

Front 49

Additional guidance concerning the applicability and use of the form are contained in the, Radiation Health Protection Manual, ____.

Back 49

NAVMED P-5055

Front 50

The ____ will include all procedures and diagnoses, and must match with information listed on the Inpatient Admission/Disposition Report (NAVMED 6300/5) and any information listed in the operation report.

Back 50

narrative summary (SF 502)

Front 51

The DD form ___ is used to order corrective prescription eyewear.

Back 51

DD 771, Eyewear Prescription

Front 52

Dental Record
Part I: ___

Back 52

All kinds of Radiographs

Front 53

Dental Record
Part II (Front of Center Page): ___

Back 53

NAVMED 6600/3, Dental Health Questionnaire (HQR)

Front 54

Dental Record
Part III (Back of Center Page): ____

Back 54

Dental Exam Forms, EZ603s (Plan “P” side up) in reverse chronological order

Front 55

Dental Record
Part IV (Inside Back Cover):

Back 55

SF 522, SF 502, SF 513, SF 509, SF 515, Previous Dental Treatment Forms (EZ603As, Old SF603s and 603As)

Front 56

The ______ is the official responsible for administering and supervising the execution of SECNAVINST 5211.5 series, Department of the Navy Privacy Act Program (PAP),

Back 56

Surgeon General of the Navy

Front 57

Department of the Navy Privacy Act Program (PAP)

Back 57

SECNAVINST 5211.5 series

Front 58

Form Number of "Certificate of Release or Discharge from Active Duty" - a document of the United States Department of Defense, issued upon a military service member's retirement, separation or discharge from active-duty military

Back 58

DD Form 214

Front 59

Retirement Year Tape
2011, 2012, 2013, 2014, 2015, 2016

Back 59

2011 yellow, 2012 white, 2013 green, 2014 red, 2015 blue, 2016 black.

Front 60

Upon completion of an annual medical record verification, the HM will make an entry on the SF 600 for medical records and black-out the corresponding year block on the front leaf of the jacket with a ______ pen.

Back 60

black felt-tip pen

Front 61

A _____ pen will be used to record all identifying data, except in the "Pencil Entries" block on the upper left of the outer front cover of these medical records.

Back 61

felt-tip or permanent black-ink pen

Front 62

Which form is used to record the outpatient treatment?

Back 62

SF 600

Front 63

For Navy and Marine Corps service members who were discharged before 31 January 1994, requests should be sent to the _____ for record retrieval.

Back 63

National Personnel Records Center (NPRC)

Front 64

For service members who were discharged after 31 January 1994, requests for record retrieval are sent to the _______.

Back 64

Department of Veterans Affairs (VA)