Lesson 4.1 General Patient Records

Front 1

Chronological

Back 1

Arranged according to the order of time.

Front 2

Dental Record

Back 2

A file of continuous dental care treatment given to all beneficiaries.

Front 3

Family Member Prefix (FMP)

Back 3

A number that designates sponsorships.

Front 4

Health Record (HREC)

Back 4

A file of continuous care given to an active duty member.

Front 5

Inpatient Record (IREC)

Back 5

A medical file which documents care provided to a patient assigned to a designated inpatient bed in a medical treatment facility (MTF) or ship.

Front 6

Outpatient Record (OREC)

Back 6

A file of continuous care which documents ambulatory treatment received by a person other than an active duty member.

Front 7

Military Treatment Facility (MTF)

Back 7

Location of military health records.

Front 8

Dose

Back 8

Measured quantity of a therapeutic agent to be administered.

Front 9

Immune

Back 9

Resistant to disease.

Front 10

Immunization

Back 10

The process by which resistance to an infectious disease is induced or augmented.

Front 11

Prophylaxis

Back 11

A means of preventing the occurrence of a disease, either by mechanical or chemical (medication) means.

Front 12

Vaccine

Back 12

A suspension of attenuated or killed microorganisms that are administered to induce active immunity to infectious disease. Vaccines may be administered intradermally, intramuscularly, subcutaneously, orally, or nasally.

Front 13

Objective

Back 13

Indicates a symptom or abnormal condition perceived by someone other than the person afflicted.

Front 14

Pertinent

Back 14

Relevant

Front 15

Subjective

Back 15

Indicates a symptom or abnormal condition produced by, or resulting from, an individual's mind or state of mind.

Front 16

Acute

Back 16

Sharp or severe; having a rapid onset, a short course, and pronounced symptoms.

Front 17

Chronic

Back 17

Long or continued; of long duration

Front 18

Comfort

Back 18

A condition of ease or well-being

Front 19

Duration

Back 19

A period of time in which something exist or lasts.

Front 20

Pain

Back 20

An unpleasant sensation, occurring in varying degrees of severity as a consequence of injury, disease, or emotional disorder.

Front 21

Admission

Back 21

A process that occurs when a patient enters a health care agency for care and treatment.

Front 22

Discharge

Back 22

To release or dismiss.

Front 23

STAT

Back 23

Immediately

Front 24

BID

Back 24

Twice a Day

Front 25

PRN

Back 25

As Needed

Front 26

CBC

Back 26

Complete Blood Count

Front 27

PR

Back 27

Pulse Rate

Front 28

NPO

Back 28

Nothing by Mouth

Front 29

PO

Back 29

by Mouth

Front 30

RR

Back 30

Respiratory Rate

Front 31

Treat Record is color-coded based on....

Back 31

the second to last digit of the sponsor's SSN

Front 32

2100

Back 32

Orange

Hint 32

0 series

Front 33

2110

Back 33

Green

Hint 33

1 series

Front 34

2120

Back 34

Yellow

Hint 34

2 series

Front 35

2130

Back 35

Gray

Hint 35

3 series

Front 36

2140

Back 36

Mustard/Tan

Hint 36

4 series

Front 37

2150

Back 37

Blue

Hint 37

5 series

Front 38

2160

Back 38

White

Hint 38

6 series

Front 39

2170

Back 39

Brown

Hint 39

7 series

Front 40

2180

Back 40

Pink

Hint 40

8 series

Front 41

2190

Back 41

Red

Hint 41

9 series

Front 42

FMP 20

Back 42

Sponsor

Front 43

FMP 30

Back 43

Spouse

Front 44

FMP 31

Back 44

Second Spouse

Front 45

FMP 01

Back 45

First Child

Front 46

FMP 02

Back 46

Second Child

Front 47

HREC Part 1

Back 47

Record of Preventive Medicine and Occupational Health and all inpatient documentation

Front 48

HREC Part 2

Back 48

Record of medical care treatment (e.g.; SF600, SF558, SF88, SF507, and SF93)

Front 49

HREC Part 3

Back 49

Physical qualifications and physical profiles.

Front 50

HREC Part 4

Back 50

Record of Ancillary Studies (e.g.; x-ray reports, lab results, and advanced directives)

Front 51

DD Form 2766

Back 51

Adult Preventive and Chronic Care Flowsheet.

Front 52

SF601 or DD Form 2766C

Back 52

Immunization Record

Front 53

DD Form 2796

Back 53

Post-Deployment Health Assessment

Front 54

DD Form 2569

Back 54

Third Party Collection Program

Front 55

AF Form 1480

Back 55

Summary of Care

Front 56

AF Form 565

Back 56

Record of Inpatient Treatment

Front 57

SF 502

Back 57

Medical Record-Narrative Summary

Front 58

SF 509

Back 58

Medical Record-Progress Notes

Front 59

NAVMED 6000/2

Back 59

Chronological Record of HIV Testing

Front 60

DD Form 2215

Back 60

Baseline Audiogram

Front 61

SF 558

Back 61

Emergency Care and Treatment

Front 62

SF 507

Back 62

Medical Record Continuation

Front 63

SF 513

Back 63

Consultation Sheet

Front 64

SF 88 or DD Form 2808

Back 64

Report of Medical Examination

Front 65

SF 93 or DD Form 2807-1

Back 65

Report of Medical History

Front 66

NAVMED 6150/4

Back 66

Abstract of Service and Medical History

Front 67

OPNAV 5211/9

Back 67

Record of Disclosure

Front 68

DD Form 2005

Back 68

Privacy Act Statement Health Care Record

Front 69

AF Form 348

Back 69

Line of Duty Determination

Front 70

AF Form 422

Back 70

Physical Profile Serial Report

Front 71

SF 519

Back 71

Radiologic Consultation Requests/Reports

Front 72

SF 545

Back 72

Laboratory Report Display

Front 73

DD Form 877

Back 73

Request for Medical/Dental Records or Information

Front 74

SF 602

Back 74

Health Record-Lab results

Front 75

NAVMED 6550/14

Back 75

Patient Data Base

Front 76

SF 502

Back 76

Narrative Summary

Front 77

SF 504

Back 77

History Part 1

Front 78

SF 505

Back 78

History Part 2 & 3

Front 79

SF 506

Back 79

Physical Exam

Front 80

SF 508

Back 80

Doctor's Orders

Front 81

SF 509

Back 81

Progress Notes

Front 82

SF 510

Back 82

Nursing Notes

Front 83

NAVMED 6550/12

Back 83

Patient Profile

Front 84

SF 511

Back 84

Vital Signs Record

Front 85

NAVMED 6550/8

Back 85

Medication Administration Record

Front 86

DD 792

Back 86

Twenty-Four Hour Intake and Output Worksheet

Front 87

Adenovirus

Back 87

One dose in BMT

Front 88

Anthrax

Back 88

Six shot series with a yearly booster that is required for personnel assigned to high threat areas

Front 89

Hepatitis A (HAV)

Back 89

Two doses over six months

Front 90

Hepatitis B (HBV)

Back 90

Three shot series that is administered over a period of six months to personnel with the risk of exposure to blood and body fluids

Front 91

Influenza

Back 91

Yearly vaccination

Front 92

Meningitis (Quadrivalent)

Back 92

One dose in basic training

Front 93

Measles, Mumps, Rubella (MMR)

Back 93

One dose

Front 94

Oral Polio

Back 94

Is no longer recommended in the US since 2000

Front 95

Tetanus-Diphtheria (Td)

Back 95

One dose every ten years

Front 96

Typhoid

Back 96

One time dose with a booster every two years for those at risk

Front 97

Varicella (chickenpox)

Back 97

Two doses that are administered to personnel who are susceptible to chickenpox

Front 98

Yellow Fever

Back 98

One dose every ten years

Front 99

Cholera

Back 99

Administered as needed by travel requirements

Front 100

Plague

Back 100

Administered as needed by travel requirements

Front 101

Smallpox

Back 101

Administered only under DOD directive 6205.3 (Biological Warfare Defense)