“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
