CHAPTER 12 HEALTH RECORDS Just as the Personnelman is responsible for the preparation and maintenance of the service record, so you, the Hospital Corpsman, are responsible in the same way for health records. A health record is the official medical history of Navy and Marine Corps personnel and eligible beneficiaries. The military health record is an individual’s chronological record of medical, dental, occupational health evaluations, and treatments. The health record is used by healthcare providers to plan and document patient care treatment. The medical history provided by the health record assists medical personnel who perform physical examinations, physical fitness evaluations, diagnosis decisions, and render care incident to injury or disease. The health record has significant medicolegal value to the patient, the medical treatment facility (MTF) and dental treatment facility (DTF), the practitioner responsible for the patient, and the U. S. Government. For example, if a military member or eligible beneficiary is injured by a nonmilitary individual (e.g., car accident) and the naval hospital provides medical care, the naval hospital would, in turn, bill the nonmilitary individual or his insurance company (third-party payer) for the medical services it provided the injured military member or beneficiary. To justify the naval hospital’s billing, send copies of medical documents from the injured individual’s health record pertaining to the injury and subsequent treatment(s) to the third-party payer. Third-party payers depend substantially upon the information recorded in the medical record. Also, various officials and boards (i.e., special duty boards and medical boards) refer to information furnished by the health record in determining physical fitness or physical disability. The health record provides statistical data for medical research, utilization management, risk management, and quality assurance. For all the reasons mentioned here, accurate and complete record entries and proper medical record maintenance are of the utmost importance. This chapter will discuss the requirements for opening, maintaining, verifying, and closing active duty and reserve personnel health records. Use of medical forms and form filing procedures will also be covered. For further details and up-to-date guidelines on health record management, as well as differences between medical records established by deployable units or under combat conditions, refer to chapter 16 of the Manual of the Medical Department (MANMED) and pertinent instructions or notices. PRIMARY AND SECONDARY MEDICAL RECORDS LEARNING OBJECTIVE: Identify the various types of primary and secondary medical records, and recall the usage of each type. Primary medical records are the original records established to document the continuation of care to service members (active and retired) and their beneficiaries. Secondary medical records are established by a patient’s healthcare provider and contain specific medical information needed by that healthcare provider. Secondary medical records are maintained separate from the primary medical record. PRIMARY MEDICAL RECORDS Three major categories of primary medical records are health records (HRECs), outpatient records (ORECs), and inpatient records (IRECs). Dental records (DRECs) are part of HRECs and ORECs. Health Record The HREC is a file of continuous care given to active duty members and documents all their outpatient care. While the HREC primarily documents ambulatory (outpatient) care, copies of inpatient narrative summaries and operative reports are also placed in the HREC to provide continuity of healthcare documentation. Outpatient Record The OREC is a file of continuous care that documents ambulatory treatment received by a person other than an active duty person. 12-1