Just as the Personnelman is responsible for the
preparation and maintenance of the service record, so
you, the Hospital Corpsman, are responsible in the
same way for health records. A health record is the
official medical history of Navy and Marine Corps
personnel and eligible beneficiaries.
The military health record is an individuals
chronological record of medical, dental, occupational
health evaluations, and treatments. The health record
is used by healthcare providers to plan and document
patient care treatment. The medical history provided
by the health record assists medical personnel who
perform physical examinations, physical fitness
evaluations, diagnosis decisions, and render care
incident to injury or disease.
The health record has significant medicolegal
value to the patient, the medical treatment facility
(MTF) and dental treatment facility (DTF), the
practitioner responsible for the patient, and the U. S.
Government. For example, if a military member or
eligible beneficiary is injured by a nonmilitary
individual (e.g., car accident) and the naval hospital
provides medical care, the naval hospital would, in
turn, bill the nonmilitary individual or his insurance
company (third-party payer) for the medical services it
provided the injured military member or beneficiary.
To justify the naval hospitals billing, send copies of
medical documents from the injured individuals
health record pertaining to the injury and subsequent
treatment(s) to the third-party payer.
payers depend substantially upon the information
recorded in the medical record. Also, various officials
and boards (i.e., special duty boards and medical
boards) refer to information furnished by the health
record in determining physical fitness or physical
The health record provides statistical data for
medical research, utilization management, risk
management, and quality assurance.
For all the
reasons mentioned here, accurate and complete record
entries and proper medical record maintenance are of
the utmost importance.
This chapter will discuss the requirements for
opening, maintaining, verifying, and closing active
duty and reserve personnel health records. Use of
medical forms and form filing procedures will also be
covered. For further details and up-to-date guidelines
on health record management, as well as differences
between medical records established by deployable
units or under combat conditions, refer to chapter 16 of
the Manual of the Medical Department (MANMED)
and pertinent instructions or notices.
PRIMARY AND SECONDARY
LEARNING OBJECTIVE: Identify the
various types of primary and secondary
medical records, and recall the usage of
Primary medical records are the original records
established to document the continuation of care to
service members (active and retired) and their
Secondary medical records are
established by a patients healthcare provider and
contain specific medical information needed by that
healthcare provider. Secondary medical records are
maintained separate from the primary medical record.
PRIMARY MEDICAL RECORDS
Three major categories of primary medical records
health records (HRECs), outpatient records
(ORECs), and inpatient records (IRECs).
records (DRECs) are part of HRECs and ORECs.
The HREC is a file of continuous care given to active
duty members and documents all their outpatient care.
While the HREC primarily documents ambulatory
(outpatient) care, copies of inpatient narrative summaries
and operative reports are also placed in the HREC to
provide continuity of healthcare documentation.
The OREC is a file of continuous care that
documents ambulatory treatment received by a person
other than an active duty person.