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30 Cards in this Set

  • Front
  • Back
When an active duty member separates from the military service and continues to receive care from the military health system, ______
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.
WHo receives an OREC folder
Every nonactive duty individual who comes for the first time to an MTF for care
When selecting a NAVMED 6150/10-19 series with a patient has no SSN, you must _____
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
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
Who is the custodian of medical records on ships, deployable units, single-billeted isolated shore locations, and branch medical annexes
The senior medical officer
Report of Medical Examination
Whenever a complete report of physical examination is required
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
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.
SF 503
Clinical Record Autopsy Protocol
The provisional anatomic diagnosis and completer autopsy protocol
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.
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
SF 509
Medical Records - Progress Notes
Describes chronologically the clinical course of the inpatient in the progress notes.
SF 513
Medical Record Consultation Sheet
The consultant must record the first assessment on the SF 513
SF 516
Medical Record Operation Report
SF 519, 519A, 519B
Medical Record Radiologic Consultation Request/Report
SF 522
Medical request of administration of anesthesia and for peformance of operations and other procedures
SF 523
Clinical Record - Authorization for Autopsy
SF 539
Medical Record -Abbreviated Medical Record - Admission of a minor nature that require 48 hours or less of hospitalization
SF 546-557
Laboratory Forms
SF 558
Medical Record - Emergency Care and Treatment (Emergency Room Records)
SF 600
Health Record - Chronological Record of Medical Care
Used for all outpatient care and file in the HREC or OREC.
SF 601
Health Record - Immunization Record
PHS 731
International Certificates of Vaccination
NAVMED 6100/1
Medical Board Report Cover Sheet
NAVMED 6150/2
Special Duty Medical Abstract
NAVMED 6150/4
Abstract of Service and Medical History
NAVMED 6150/20
Summary of Care
DD 602
Evacuation Tag
NAVMED 6300/5
Inpatient Admission/Disposition Record
DD 771
Eyewear Prescription