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30 Cards in this Set
- Front
- Back
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When an active duty member separates from the military service and continues to receive care from the military health system, ______
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a copy of the HREC is made and a new folder is prepared and identifiel Outpatient record(OREC), for retention at the MTF. Documents will be stamped DUPLICATE RECORD.
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WHo receives an OREC folder
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Every nonactive duty individual who comes for the first time to an MTF for care
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When selecting a NAVMED 6150/10-19 series with a patient has no SSN, you must _____
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Assign a pseudo SSN aas follows: 800 for the first three digits, the year, month, day of birth (i.e. 800-YY-MM-DD) for the remaining six digits
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FMP
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Mother, Step 40-44
Father, Step 45-49 Mother-in-Law 50-54 Father-in-Law 55-59 Other authorized dependants 60-69 Beneficiary authorized by statue 90-95 Civilian emergencies 98 All others 99 |
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Who is the custodian of medical records on ships, deployable units, single-billeted isolated shore locations, and branch medical annexes
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The senior medical officer
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SF88
Report of Medical Examination |
Whenever a complete report of physical examination is required
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SF93
Report of Medical History |
Provide a complete personal medical history and a source of information supplemental to that reported on the SF 88. Provides a current, concise, and comprehensive record of an examinee's personal medical history before entrance the naval service
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SF 502
Medical Record Narrative Summary (Clinical Record) |
Used to provide a brief accurate account of the care and treatment given. Must agree with those listed on the Inpatient Admission/Disposition Record.
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SF 503
Clinical Record Autopsy Protocol |
The provisional anatomic diagnosis and completer autopsy protocol
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SF 504
Clinical Record-History Part 1 SF 505 Clinical Record-History Part 2 SF 506 Clinical Record-Physical Examination |
Prepare and sign an admission workup.
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SF 508
Doctor's Orders |
ALL orders for for diagnostic procedures, treatment, medication, transfer, or disposition record legibly in black ink or type written, dated and signed by the HP
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SF 509
Medical Records - Progress Notes |
Describes chronologically the clinical course of the inpatient in the progress notes.
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SF 513
Medical Record Consultation Sheet |
The consultant must record the first assessment on the SF 513
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SF 516
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Medical Record Operation Report
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SF 519, 519A, 519B
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Medical Record Radiologic Consultation Request/Report
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SF 522
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Medical request of administration of anesthesia and for peformance of operations and other procedures
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SF 523
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Clinical Record - Authorization for Autopsy
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SF 539
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Medical Record -Abbreviated Medical Record - Admission of a minor nature that require 48 hours or less of hospitalization
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SF 546-557
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Laboratory Forms
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SF 558
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Medical Record - Emergency Care and Treatment (Emergency Room Records)
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SF 600
Health Record - Chronological Record of Medical Care |
Used for all outpatient care and file in the HREC or OREC.
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SF 601
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Health Record - Immunization Record
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PHS 731
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International Certificates of Vaccination
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NAVMED 6100/1
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Medical Board Report Cover Sheet
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NAVMED 6150/2
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Special Duty Medical Abstract
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NAVMED 6150/4
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Abstract of Service and Medical History
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NAVMED 6150/20
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Summary of Care
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DD 602
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Evacuation Tag
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NAVMED 6300/5
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Inpatient Admission/Disposition Record
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DD 771
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Eyewear Prescription
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