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Sample of completed outside front cover and inside back cover of a health record jacket
Table 12-1.Sequential List of Health Record Forms

Hospital Corpsman Revised Edition - Complete Navy Nursing manual for hospital training purposes
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“GENERAL OFFICER,” as appropriate, on the lower portion of the patient identification box. If a patient identification label is used, print or stamp the appropriate identification below the label. PENCIL ENTRIES.—Following the instructions on the front cover, pencil in the appropriate title (i.e., grade or rate, if on active duty; preferred form of address, if retired or civilian), and include the current command (if active duty). RECORD RETIREMENT TAPE BOX.— Leave the record retirement tape box on the inside back cover blank. BAR CODE.—Some Navy medical facilities have bar coding capabilities. The bar code label indicates the patient’s FMP, SSN, record type, and record volume number. Affix the label to the front of the record jacket in the box right of the alert box. If the bar code is part of the patient identification label (such as the patient identification label produced by the Composite Health Care System (CHCS) computers), place this label in the patient identification box. LABELS.—Use of a self-adhesive label with the name of the MTF, ship, or other units having custodial responsibility for the record is optional. Ship or MTF logos are permitted as long as the necessary patient identifying information is not obscured. For further details see the appropriate MANMED article covering this subject. Preparing the Inside Front Cover Enter the following information in pencil on the inside front cover of the HREC jacket. Record the information in the inside of the front cover in pencil to permit changes and updating.  Date of arrival  Projected departure date  Home address and telephone number  Duty station and telephone number Preparing the Middle Section The middle section of the HREC contains a preprinted DD 2005, Privacy Act Statement—Health Care Records, on the front side. When opening an HREC, the service members are asked to read the Privacy Act Statement. After the members have read the statement, they will need to sign, date, and include their SSN at the bottom of the form. Signing this statement indicates the service members understand their right to confidentiality in regard to the medical documentation placed in their HREC. On the reverse of the middle section is a Disclosure Accounting Record. This form should be annotated whenever the HREC is released to any individual or agency outside the MTF. SEQUENCE OF HEALTH RECORD FORMS When assembling an HREC, you should arrange the forms in chronological order by date. The most current document should be placed on top, and the least current documents below it. The HREC contains dividers that partition the record into four parts. A sequential listing of medical forms to be filed in each section is provided in table 12-1. The titles for each part of the HREC are as follows: Part 1. Record of Preventive Medicine and Occupational Health Part 2. Record of Medical Care and Treat- ment Part 3. Physical Qualifications Part 4. Record of Ancillary Studies, Inpatient Care, and Miscellaneous Forms HEALTH RECORD FORMS LEARNING OBJECTIVE: Recall the purpose and completion procedures for the health record forms discussed in this section. In the last section, you learned there are many medical forms placed in the health record. Also, you learned each form has a specific location within the record. The methods for the management of major areas of health care, both ashore and afloat, are rapidly changing. The Composite Health Care System (CHCS), a secure, computer-based system, is now the primary means that healthcare practitioners use to schedule and process patient visits, track medical results, order labs and x-rays, and process orders for medications. CHCS is especially valuable for pier-side healthcare providers and furnishes a much higher standard for patient care. Computerized medical documentation (e.g., laboratory test results, emergency room reports, etc.) 12-9







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