The following information will be entered on the inside of the jacket front leaf in pencil to allow for changes:
Record Identifier for Personnel Reliability (NAVPERS 5510/1)
The purpose of this form is to readily identify members of the Navy and Marine Corps assigned to the Nuclear Weapons Personnel Reliability Program in accordance with applicable service directives. Medical officers and Medical Department representatives shall familiarize themselves with the Nuclear Weapons Personnel Reliability Manual, NAVMED P-5090, for proper administration of the program. This form is to be retained as the topmost form in the health record at all times. If the member is no longer in the program, remove and destroy NAVPERS 5510/1 and make appropriate explanatory entries on SF 600.
The Problem Summary List list (figure 10-3) contains a summation of relevant problems and medications that significantly affect the patients health status. Properly maintained, the list facilitates coordinated management of the patients health condition.
Entries on NAVMED 6150/20 should include, but are not limited to, significant medical and surgical conditions, allergies, untoward reactions to medication, and medications currently using or recently used. The problem summary list should be reviewed and revised as necessary at the time of the patients visit.
Thechronological Record of Medical Care (figs. 10-4 and 10-4A) provides a current, concise, and comprehensive record of a members military medical history. Properly maintained, it facilitates the evaluation of a patients physical condition, reduces correspondence necessary to obtain medical records, eliminates unnecessary repetition of expensive diagnostic procedures, and serves as an invaluable permanent record of medical evaluations and treatments.
Entries will be typewritten when practical (except sick call treatment entries which may be handwritten in black or blue-black ink). They will include the date, the name and address of the activity responsible for the entry, and the signature of the responsible medical officer or the Medical Department representative. When a new SF 600 is initiated, the identification block shall be completed with the patients name, grade or rank, SSN, sex, organization, date of birth, and the name of the organization that maintains the record.
SF 600 is continuous and includes the following information as indicated: complaints, duration of illness or injury, physical findings, clinical course, results of laboratory or other special examinations, treatment (including operations), physical fitness at the time of disposition, and disposition.
Specific SF 600 entries include, but are not limited to the following:
Whenever a member is evaluated at sick call, an entry will be made on SF 600, reflecting the complaints or conditions presented, pertinent history, treatment rendered, and disposition.
Each admission for injury or poisoning is recorded in accordance with BUMEDINST 6300.3 series (Inpatient Data System) and the International Classification of Diseases, Adapted, (ICDA) Vol. 1.
Each entry, from admission to final disposition, will be complete with regard to time, date, place, circumstances, diagnosis for which treated, and the signature of the medical officer or Medical Department representative.