Inpatient RecordThe IREC is a medical file that documents careprovided to a patient (inpatient) assigned to adesignated inpatient bed in an MTF or ship.SECONDARY MEDICAL RECORDSSecondary medical records are separate from theprimary medical record and must follow the guidelinesestablished by the MANMED and the local medicalrecords committee. These records are kept in aseparate file secured in a specialty clinic or departmentof fixed MTFs (e.g., naval hospitals and branchmedical clinics). The secondary medical recordsinclude convenience records, temporary records, andancillary records.Because primary healthcare providers of activeduty personnel must be aware of their crew’s medicalstatus at all times, temporary and ancillary records willnot be opened or maintained for active duty personnel.The exceptions to this policy are records forobstetrics/gynecology (OB/GYN), family advocacy,and psychology and psychiatry clinical records.The healthcare provider creating a secondarymedical record should write a note stating the nature ofthe secondary record, the patient’s diagnosis, and theclinic or department name, address, and telephonenumber on the NAVMED 6150/20, Summary of Care,of the patient’s primary medical record. Thehealthcare provider should make a second note entryon the NAVMED 6150/20 when the secondary recordis closed.Convenience RecordA convenience record contains excerpts from apatient’s primary record and is kept within the MTF bya treating clinic, service, department, or individualprovider for increased access to the information.When the convenience record’s purpose has beenserved, the establishing clinic, service, department, orprovider purges the record from its file, compares it tothe primary medical record, and adds any medicaldocuments that are not already in the primary medicalrecord.Temporary RecordA temporary record is an original medical recordestablished and retained in a specialty clinic, service,or department in addition to the patient’s primarymedical record. Its purpose is to document a currentcourse of treatment. The temporary medical recordbecomes a part of the primary medical record when thecourse of treatment is concluded. This record is mostcommonly established in OB/GYN for a prenatalpatient.Ancillary RecordAncillary records consist of original healthcaredocumentation withheld from a patient’s primaryHREC or OREC. In certain cases it may be advisableto not file original treatment information in the primarytreatment record, but instead place this informationinto a secondary medical record, to which the patient,parent, or guardian has limited access. Examples ofsuch instances include information that is potentiallyinjurious to the patient, or information that requiresextraordinary degrees of protection (such aspsychiatric treatment or instances of real or suspectedchild or spouse abuse, etc).THE MEDICAL RECORDLEARNING OBJECTIVE:Recallcustody guidelines for medical records.All medical records are the property of the U.S.Government and must be maintained by MTFs (navalhospitals, medical clinics, and medical departments ofships, submarines, aviation squadrons, and isolatedduty locations) that have primary cognizance over thecare of the patient. Medical records are of continuinglong-term interest to the government and the patientand must be maintained within an MTF. Patients maynot retain original HRECs, ORECs, or dental records.Hand-carrying medical records by unauthorizedindividuals (e.g., spouses or siblings of the patient)without written permission is prohibited.HEALTH RECORD CUSTODYThe HREC is retained in the custody of the medicalofficer on the ship, submarine, or aviation squadron towhich the member is assigned. For those ships,submarines, and aviation squadrons that do not havemedical officers, the health record may be placed in thecustody of the medical department representative(MDR) at the discretion of the commanding officer(CO). Examples of MDRs are Independent DutyCorpsman or Squadron Corpsman. When Medical12-2
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