Purpose of Records
What is the primary purpose of a health record?
A chronological record of medical treatment afforded members of the naval service.
When is a new health treatment record (HREC) opened?
Upon initial entry into the naval service (member’s first day).
Who owns the medical record, and which facility has primary responsibility for maintaining it?
The U.S. Government owns the medical record, and the treating Medical or Dental Treatment Facility (MTF/DTF) maintains custody of it.
Before transferring a health treatment record to another duty station, which related record must accompany it?
The member's dental record should accompany the health treatment record when it is transferred to a new duty station.
What filing system is commonly used to organize health treatment records by service members' Social Security numbers?
The Terminal Digit Filing System, which organizes records by the last two digits of the member's Social Security number.
Name one of the groups for which the health record has current and long-term medico-legal value.
The individual concerned, their survivors, or the U.S. Government.
At what time is a separate dental treatment record prepared for new personnel?
At the first dental visit after entry into service or whenever a dental record has not already been initiated.
Onboard ships, who has custodial responsibilities for health treatment records?
The senior medical department representative (SMDR) or senior medical officer (SMO) with authority from the commanding officer.
What is the name and number of the charge‑out receipt card (the pink card) used when forwarding a health treatment record?
NAVMED 6150/7, the Health Record Receipt (commonly known as the pink Charge‑Out Card).
How frequently should health treatment records be verified, and when is the annual verification typically performed?
Health records are verified upon check‑in to or check‑out from a command and before physical examinations; an annual verification is performed during the service member's birth month.
Besides planning patient care, what is another use of a Health Record?
Evidence of evaluation or treatment, communication between health care providers, and legal protection for the patient, medical/dental treatment facilities, and the U.S. Navy.
What happens to an existing HREC when a midshipman or enlisted member is appointed to a commissioned or warrant grade?
Continue using the same HREC; make a summary entry on the SF 600 and complete a NAVMED 6150/4 to close out prior enlisted service, then continue entries under the commissioned or warrant status.
When a patient is hospitalized at a naval MTF, what records must accompany the patient?
Their health record (HREC or outpatient record) and a copy of the inpatient record (IREC), including when they are aeromedically transferred.
How long should the charge‑out receipt card (NAVMED 6150/7) be retained on file after a health treatment record is forwarded to another duty station?
Keep the pink Health Record Receipt on file for at least one year after the health record is forwarded (or until the original record is returned and the card is no longer needed).
What information should be documented on the SF 600 when completing the annual verification of a health treatment record?
An entry should be made on the SF 600 noting "Annual Verification" or "Health Record Verified" with the date and the initials or signature of the reviewer, confirming that all required forms and immunizations are present and up to date.
Provide two additional purposes of the health record beyond patient care planning.
It provides data for continuing education and research, justifies costs incurred by third‑party payers, and serves as a vehicle for communication among health care providers, utilization management, risk management, quality assurance, medical records personnel, and outside agencies.
Name two circumstances that cause a health record to be closed according to Article 23.
When the member dies or is declared dead, is discharged, resigns, is released from active duty, retires, transferred to the Fleet Reserve, declared missing or a deserter, or is disenrolled from a program.
When a member is transferred to a Veterans Affairs Medical Center (VAMC), what actions should be taken with their Health Record and Inpatient Record?
Forward a copy of the HREC and inpatient record (including any medical board reports) to the VAMC, and send the original health record to the naval hospital or medical treatment facility where the board was convened or where the member is assigned.
If a health treatment record is lost or not available, what notation should be recorded on the SF 600 to document the situation?
Make an administrative entry on the SF 600 indicating that the health record is lost or not available, noting the date it was discovered missing and summarizing the efforts taken to locate it.
What is the proper method for correcting an erroneous entry in a health treatment record?
Draw a single line through the incorrect entry so that the original writing remains legible, enter the correct information nearby, and initial and date the correction; never erase, white‑out or obscure the original entry.
Health records serve as a communication vehicle among various groups. Name at least three of these groups.
Health care providers, utilization management, risk management, quality assurance, medical records personnel, and outside agencies.
What three pieces of information must be included in the closing entry on NAVMED 6150/4 (Abstract of Service and Medical History)?
Date of separation, title of the servicing activity, and any explanatory circumstances regarding the separation.
When a patient is hospitalized in a civilian medical facility, under what circumstance should their health record be forwarded and to whom is it sent?
If the duration of the civilian hospitalization is expected to be significant, forward the health record to the civilian facility (through the appropriate medical authority) for continuity of care. Once treatment is completed, the record should be returned to the service member's command or supporting medical treatment facility.
When a health record has been lost or destroyed and cannot be recovered, what should be done to replace it, and how is the new record identified?
Prepare a replacement health record and stamp or type "REPLACEMENT" on the front of the record jacket. Include a brief explanation on an SF 600 entry detailing the circumstances. If the original record is later found, merge it with the replacement.
Which dental classification indicates that a patient has oral conditions likely to cause a dental emergency within the next 12 months and therefore requires urgent treatment?
Dental Class 3 designates patients with oral conditions that are expected to cause dental emergencies within the next 12 months.