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31 Cards in this Set
- Front
- Back
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MANMED P-117 |
Manual of the MedicalDepartment |
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PRIMARY MEDICAL RECORDS |
- Outpatient - Dental care |
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SECONDARY MEDICAL RECORDS |
specialty healthcare |
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Three major categories of primarymedical records are: |
Health records (HRECs) Outpatient records (ORECs) - Dental Records (DRECs) Inpatient records (IRECs) |
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Health Record |
continuous care givento active duty members |
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Dental Records |
continuous care givento active duty and reserve members and theirfamilies |
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Outpatient Record |
continuous care received by aperson other than an active duty person, i.e.retiree and family members. (OUT - of the military) |
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Inpatient Record |
inpatient bed at an MTF or ship. Summaries goes HREC (AD) OREC (NON AD) |
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SECONDARY MEDICAL RECORDS |
These records are kept in a separatefile and secured in a specialty clinic ordepartment of MTFs. |
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DD2766 |
Chronic Care Flow Sheet |
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Secondary medical records include: |
Convenience records Temporary records Ancillary records |
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Convenience Record |
keptwithin the MTF by a treating clinic, for increasedaccess to the information. (CONVENIENT RECORD=LAZY RECORD) |
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Temporary Medical Record |
Its purpose isto document a current course of treatment (commonly established in OB/GYN ) |
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Temporary Dental Records |
current course of treatment Ex; Sailor TAD without his record, requires emergency dental Tx |
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The temporary dental record must, at aminimum contain the following forms: |
Privacy Act, DD 2005 Dental Health Questionnaire, NAVMED6600/3 Dental Treatment Form, EZ603A (Zero, zero-zero, zero-z zero) |
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Ancillary Record |
originalhealthcare documentation withheld from apatient’s primary HREC or OREC |
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RECORDS MANAGEMENT responsability |
The CommandingOfficer (CO) has ultimate responsibility for allmedical records. |
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OPENING HEALTH RECORDS |
Records areopened when: - Individual becomes a Navy or Marine Corps - when a retired is returned to active duty, - Original record is lost ordestroyed. (only AD or lost) |
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Family member prefix |
Sponsor20 Children01-19(First Child 01, Second Child 02, etc.) Spouse30(First Spouse 30, Second Spouse 31, etc.) Mother, Stepmother40-44 Father, Stepfather45-49 Mother-in-law50-54 Father-in-law55-59 Other Authorized Dependents60-69 Beneficiary Authorized by Statute90-95 Civilian Emergencies98 All Others99 |
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NAME ON MEDICAL RECORD |
Enter last, first, middle initial, in that order - in the upper-right corner. Indicate no middle name by "NMN." |
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Alert Box (Front of medical record) |
used to indicate member has drug sensitivities or allergies |
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Category of the record |
Enter a X in appropriate box Indicate if: Dental, Outpatient record. Red Tape indicates active duty. |
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Special Categories Records |
Special Duty (Flight Status...) Medical Surveillance Program (Radiation, Asbestos Exposure). |
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Special Category Record Cont (Test question) |
Identify flag officers by printing “FLAG OFFICER” or "GENERAL OFFICER," on the lower portion of the patient identification box. If a patient identification label is used, print or stamp the appropriate identification below the label. |
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Preparing Part I (Inside Front Cover) |
Date of arrival Projected rotation date Home address and telephone number Command UIC and telephone number |
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Preparing Part II (Front of Center Page) |
IMPRINT OF DD 2005, PRIVACY ACT STATEMENT.
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Preparing Part III (Back of Center Page) |
DISCLOSURE ACCOUNTING RECORD |
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Preparing Part IV (Inside Back Cover) |
The Forensic Examination form |
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RECORD FILING SYSTEM Terminal Digit Filing System (TDFS) SSN Example; 123-45-6789 |
Primary Number: 89 Secondary Number: 67 Third Number: 123-45 |
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Record Color Stock |
Orange , Green, Yellow ,Grey ,Tan ,Blue , White ,Almond ,Pink,Red (OUR GOLDEN YEARS GET TOUGH BUT WE ARE PRETTY REGULAR ) |
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HEALTH RECORD CLOSURE |
Only when you are not a AD anymore. (Ex: Death, retirement, Discharged, Deserter...) |
