“GENERAL OFFICER,” as appropriate, on the lowerportion of the patient identification box. If a patientidentification label is used, print or stamp theappropriate identification below the label.PENCIL ENTRIES.—Following the instructionson the front cover, pencil in the appropriate title (i.e.,grade or rate, if on active duty; preferred form ofaddress, if retired or civilian), and include the currentcommand (if active duty).RECORD RETIREMENT TAPE BOX.—Leave the record retirement tape box on the inside backcover blank.BAR CODE.—Some Navy medical facilitieshave bar coding capabilities. The bar code labelindicates the patient’s FMP, SSN, record type, andrecord volume number. Affix the label to the front ofthe record jacket in the box right of the alert box. If thebar code is part of the patient identification label (suchas the patient identification label produced by theComposite Health Care System (CHCS) computers),place this label in the patient identification box.LABELS.—Use of a self-adhesive label with thename of the MTF, ship, or other units having custodialresponsibility for the record is optional. Ship or MTFlogos are permitted as long as the necessary patientidentifying information is not obscured. For furtherdetails see the appropriate MANMED article coveringthis subject.Preparing the Inside Front CoverEnter the following information in pencil on theinside front cover of the HREC jacket. Record theinformation in the inside of the front cover in pencil topermit changes and updating.Date of arrivalProjected departure dateHome address and telephone numberDuty station and telephone numberPreparing the Middle SectionThe middle section of the HREC contains apreprinted DD 2005, Privacy Act Statement—HealthCare Records, on the front side. When opening anHREC, the service members are asked to read thePrivacy Act Statement. After the members have readthe statement, they will need to sign, date, and includetheir SSN at the bottom of the form. Signing thisstatement indicates the service members understandtheir right to confidentiality in regard to the medicaldocumentation placed in their HREC.On the reverse of the middle section is a DisclosureAccounting Record. This form should be annotatedwhenever the HREC is released to any individual oragency outside the MTF.SEQUENCE OF HEALTH RECORD FORMSWhen assembling an HREC, you should arrangethe forms in chronological order by date. The mostcurrent document should be placed on top, and the leastcurrent documents below it. The HREC containsdividers that partition the record into four parts. Asequential listing of medical forms to be filed in eachsection is provided in table 12-1. The titles for eachpart of the HREC are as follows:Part 1. Record of Preventive Medicine andOccupational HealthPart 2. Record of Medical Care and Treat-mentPart 3. Physical QualificationsPart 4. Record of Ancillary Studies, InpatientCare, and Miscellaneous FormsHEALTH RECORD FORMSLEARNING OBJECTIVE:Recall thepurpose and completion procedures for thehealth record forms discussed in thissection.In the last section, you learned there are manymedical forms placed in the health record. Also, youlearned each form has a specific location within therecord. The methods for the management of majorareas of health care, both ashore and afloat, are rapidlychanging. The Composite Health Care System(CHCS), a secure, computer-based system, is now theprimary means that healthcare practitioners use toschedule and process patient visits, track medicalresults, order labs and x-rays, and process orders formedications. CHCS is especially valuable forpier-side healthcare providers and furnishes a muchhigher standard for patient care.Computerized medical documentation (e.g.,laboratory test results, emergency room reports, etc.)12-9
Integrated Publishing, Inc. - A (SDVOSB) Service Disabled Veteran Owned Small Business