CHAPTER 12HEALTH RECORDSJust as the Personnelman is responsible for thepreparation and maintenance of the service record, soyou, the Hospital Corpsman, are responsible in thesame way for health records. A health record is theofficial medical history of Navy and Marine Corpspersonnel and eligible beneficiaries.The military health record is an individual’schronological record of medical, dental, occupationalhealth evaluations, and treatments. The health recordis used by healthcare providers to plan and documentpatient care treatment. The medical history providedby the health record assists medical personnel whoperform physical examinations, physical fitnessevaluations, diagnosis decisions, and render careincident to injury or disease.The health record has significant medicolegalvalue to the patient, the medical treatment facility(MTF) and dental treatment facility (DTF), thepractitioner responsible for the patient, and the U. S.Government. For example, if a military member oreligible beneficiary is injured by a nonmilitaryindividual (e.g., car accident) and the naval hospitalprovides medical care, the naval hospital would, inturn, bill the nonmilitary individual or his insurancecompany (third-party payer) for the medical services itprovided the injured military member or beneficiary.To justify the naval hospital’s billing, send copies ofmedical documents from the injured individual’shealth record pertaining to the injury and subsequenttreatment(s) to the third-party payer. Third-partypayers depend substantially upon the informationrecorded in the medical record. Also, various officialsand boards (i.e., special duty boards and medicalboards) refer to information furnished by the healthrecord in determining physical fitness or physicaldisability.The health record provides statistical data formedical research, utilization management, riskmanagement, and quality assurance. For all thereasons mentioned here, accurate and complete recordentries and proper medical record maintenance are ofthe utmost importance.This chapter will discuss the requirements foropening, maintaining, verifying, and closing activeduty and reserve personnel health records. Use ofmedical forms and form filing procedures will also becovered. For further details and up-to-date guidelineson health record management, as well as differencesbetween medical records established by deployableunits or under combat conditions, refer to chapter 16 ofthe Manual of the Medical Department (MANMED)and pertinent instructions or notices.PRIMARY AND SECONDARYMEDICAL RECORDSLEARNING OBJECTIVE: Identify thevarious types of primary and secondarymedical records, and recall the usage ofeach type.Primary medical records are the original recordsestablished to document the continuation of care toservice members (active and retired) and theirbeneficiaries. Secondary medical records areestablished by a patient’s healthcare provider andcontain specific medical information needed by thathealthcare provider. Secondary medical records aremaintained separate from the primary medical record.PRIMARY MEDICAL RECORDSThree major categories of primary medical recordsare health records (HRECs), outpatient records(ORECs), and inpatient records (IRECs). Dentalrecords (DRECs) are part of HRECs and ORECs.Health RecordThe HREC is a file of continuous care given to activeduty members and documents all their outpatient care.While the HREC primarily documents ambulatory(outpatient) care, copies of inpatient narrative summariesand operative reports are also placed in the HREC toprovide continuity of healthcare documentation.Outpatient RecordThe OREC is a file of continuous care thatdocuments ambulatory treatment received by a personother than an active duty person.12-1
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