CHAPTER 10 HEALTH RECORDS
INTRODUCTION
While the personnelman is responsible for the preparation and maintenance of the service record, you, the hospital corpsman, are responsible in the same way for health records. A health record is the official medical and dental history of Navy or Marine Corps personnel and eligible beneficiaries.
In this chapter, we will discuss the requirements for opening, closing, verifying, and the custody of the health record. We will also cover the different component health record forms and their sequential placement in the health records.
THE HEALTH RECORD
The military health treatment record (medical and dental) is an individual chronological record and a concise summary of all medical and dental examinations, evaluations, and treatments afforded to a member of the Navy or Marine Corps.
It provides valuable assistance to Medical Department personnel in conducting examinations, evaluating physical fitness, making diagnoses, and rendering medical or dental care in the treatment of injury or disease.
The health record has significant medicolegal value to the member concerned, the member’s beneficiaries, and the Government. Proper and equitable determination of claims based upon physical disability is largely dependent upon the information recorded in the health record.
Various officials and boards refer to information furnished by the health record in determining physical fitness.
It is often the determinant factor in the adjustment of internal revenue assessment and in the establishment of veterans’ preference.
It affords basic data for the compilation of medical statistics.
The dental record is an invaluable aid in the identification of the deceased, especially when other means fail. It is also the source of dental operational readiness data.
Accuracy is of utmost importance in the recording of all entries, especially for periods of combat.
The inclusion of special examinations, consultations, and laboratory and x-ray reports is vital to an individual’s record. If they are not on adjunct health record forms, they should be transcribed into the record to prevent loss of information.
The various circumstances under which a health record may be opened, closed, and maintained are described in detail in the Manual of the Medical Department (MANMED), chapter 16. Additional information is presented in the Navy Directives System.
Implementation of a new program may require modification of existing regulations to fit the particular need. Therefore, all personnel associated with health record maintenance must keep abreast not only of MANMED but also of all directives to ensure that correct procedures are used.
OPENING THE HEALTH RECORD
A health record is opened when an individual becomes a member of the naval service, when a member on the retired list is returned to active duty, or when the original record has been lost or destroyed. All applicable spaces on each of the component forms designated for personal identification data will be completed. Official abbreviation of grade or rate will be used. The social security numbers (SSNs) of officers will be followed by the designator code or MOS as appropriate, except on SF 88 (Report of Medical Examination) where the designator code or MOS will follow the grade and component in block 2. All SSNs will be preceded by the family member prefix code.
Officers
A health record will be opened at the time of acceptance of appointment for individuals appointed from civilian life, and the record will be forwarded to the initial place of active duty. If the member is appointed and retained on inactive duty, the record will be disposed of as follows:
1. Class II Marine Corps reservists—Forward to or retain at the Organized Marine Corps Reserve unit to which assigned.