The IREC is a medical file that documents care
provided to a patient (inpatient) assigned to a
designated inpatient bed in an MTF or ship.
SECONDARY MEDICAL RECORDS
Secondary medical records are separate from the
primary medical record and must follow the guidelines
established by the MANMED and the local medical
These records are kept in a
separate file secured in a specialty clinic or department
of fixed MTFs (e.g., naval hospitals and branch
The secondary medical records
include convenience records, temporary records, and
Because primary healthcare providers of active
duty personnel must be aware of their crews medical
status at all times, temporary and ancillary records will
not be opened or maintained for active duty personnel.
The exceptions to this policy are records for
obstetrics/gynecology (OB/GYN), family advocacy,
and psychology and psychiatry clinical records.
The healthcare provider creating a secondary
medical record should write a note stating the nature of
the secondary record, the patients diagnosis, and the
clinic or department name, address, and telephone
number on the NAVMED 6150/20, Summary of Care,
of the patients primary medical record.
healthcare provider should make a second note entry
on the NAVMED 6150/20 when the secondary record
A convenience record contains excerpts from a
patients primary record and is kept within the MTF by
a treating clinic, service, department, or individual
provider for increased access to the information.
When the convenience records purpose has been
served, the establishing clinic, service, department, or
provider purges the record from its file, compares it to
the primary medical record, and adds any medical
documents that are not already in the primary medical
A temporary record is an original medical record
established and retained in a specialty clinic, service,
or department in addition to the patients primary
medical record. Its purpose is to document a current
course of treatment. The temporary medical record
becomes a part of the primary medical record when the
course of treatment is concluded. This record is most
commonly established in OB/GYN for a prenatal
Ancillary records consist of original healthcare
documentation withheld from a patients primary
HREC or OREC. In certain cases it may be advisable
to not file original treatment information in the primary
treatment record, but instead place this information
into a secondary medical record, to which the patient,
parent, or guardian has limited access. Examples of
such instances include information that is potentially
injurious to the patient, or information that requires
extraordinary degrees of protection (such as
psychiatric treatment or instances of real or suspected
child or spouse abuse, etc).
THE MEDICAL RECORD
custody guidelines for medical records.
All medical records are the property of the U.S.
Government and must be maintained by MTFs (naval
hospitals, medical clinics, and medical departments of
ships, submarines, aviation squadrons, and isolated
duty locations) that have primary cognizance over the
care of the patient. Medical records are of continuing
long-term interest to the government and the patient
and must be maintained within an MTF. Patients may
not retain original HRECs, ORECs, or dental records.
Hand-carrying medical records by unauthorized
individuals (e.g., spouses or siblings of the patient)
without written permission is prohibited.
HEALTH RECORD CUSTODY
The HREC is retained in the custody of the medical
officer on the ship, submarine, or aviation squadron to
which the member is assigned.
For those ships,
submarines, and aviation squadrons that do not have
medical officers, the health record may be placed in the
custody of the medical department representative
(MDR) at the discretion of the commanding officer
Examples of MDRs are Independent Duty
Corpsman or Squadron Corpsman.