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Questions and Answers
What is Chapter 16 of the NAVMED P-117?
What is Chapter 16 of the NAVMED P-117?
Medical Records
Who is the point of contact for all inquiries and recommendations for improvement to the systems, procedures, and forms of NAVMED P-117, chapter 16?
Who is the point of contact for all inquiries and recommendations for improvement to the systems, procedures, and forms of NAVMED P-117, chapter 16?
Chief, Bureau of Medicine and Surgery, BUMED
What are the medical records used for? (Select all that apply)
What are the medical records used for? (Select all that apply)
What are the original records established to document the continuation of care given to a beneficiary?
What are the original records established to document the continuation of care given to a beneficiary?
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What are the 3 major categories of primary records?
What are the 3 major categories of primary records?
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Dental records are part of what primary records?
Dental records are part of what primary records?
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What is a file of continuous care given to an ACTIVE duty member?
What is a file of continuous care given to an ACTIVE duty member?
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What is a file of continuous care which documents ambulatory treatment received by a person other than an active duty member?
What is a file of continuous care which documents ambulatory treatment received by a person other than an active duty member?
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What is a medical file which documents care provided to a patient assigned to a designated inpatient bed in an MTF or a ship?
What is a medical file which documents care provided to a patient assigned to a designated inpatient bed in an MTF or a ship?
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What are the types of secondary records?
What are the types of secondary records?
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What type of record contains copies of excerpts from a patient's primary treatment record and is kept within the MTF?
What type of record contains copies of excerpts from a patient's primary treatment record and is kept within the MTF?
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To ensure the timely availability of information that documents a current course of treatment is the purpose of what type of medical record?
To ensure the timely availability of information that documents a current course of treatment is the purpose of what type of medical record?
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To conserve the more expensive terminal digit SSN folders, what can be used for temporary medical records?
To conserve the more expensive terminal digit SSN folders, what can be used for temporary medical records?
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Ex-service maternity patients are considered what type of patients?
Ex-service maternity patients are considered what type of patients?
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What consists of original health care documentation withheld from a patient's primary health record?
What consists of original health care documentation withheld from a patient's primary health record?
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What should be stamped or printed on the NAVMED 6150/20 of the primary HREC or OREC if a secondary record is used?
What should be stamped or printed on the NAVMED 6150/20 of the primary HREC or OREC if a secondary record is used?
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What is used to provide a brief, accurate account of the care and treatment given to a patient?
What is used to provide a brief, accurate account of the care and treatment given to a patient?
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Study Notes
NAVMED P-117 Chapter 16: Medical Records
- Chapter 16 covers the guidelines and procedures for managing medical records in the Navy.
- The Chief, Bureau of Medicine and Surgery (BUMED) serves as the point of contact for inquiries related to this chapter.
Purpose of Medical Records
- Medical records are essential for planning patient care and documenting evaluations of patient conditions.
- They provide legal protection for the patient, healthcare provider, and the government.
- Serve as secondary evidence to justify costs incurred by third parties.
Types of Medical Records
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Primary Records: Document continuous care for beneficiaries, categorized into health records, outpatient records, and inpatient records.
- Health Record: Continuous care file for active duty members.
- Outpatient Record: Documents care for non-active duty individuals.
- Inpatient Record: Details care provided to patients assigned to hospital beds.
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Secondary Records: Include convenience, temporary, and ancillary records.
- Convenience Record: Contains excerpts from primary treatment records for internal use.
- Temporary Record: Ensures timely access to patient treatment information.
- Ancillary Record: Hold original health care documents withheld from the primary record.
Record Management Procedures
- Use manila folders for temporary medical records to conserve costly digit folders.
- Ex-service maternity patients are classified as SECNAV Designees.
- The Medical Records Committee (MRC) oversees record management and meets quarterly.
Documentation Standards
- JCAHO establishes minimum requirements for medical records in MTFs.
- Records must be coded and completed within 30 days post-discharge for JCAHO accreditation.
Forms and Implementation
- Various forms are used for different medical documentation needs, such as:
- NAVMED 6150/20: Summary of Care, essential in all medical records.
- SF 88: Report of Medical Examination required for physical exam documentation.
- SF 93: Provides a detailed personal medical history.
- SF 502: Brief narrative of the patient's care and treatment provided.
Patient Privacy and Consent
- Sensitive information regarding a patient’s diagnosis requires informed consent before being disclosed.
- The MTF or DTF maintains ownership and custody of all medical records.
Special Cases and Requirements
- Employees of the Navy have separate medical records under the Employee Medical File (EMF).
- For records transferred between MTFs, strict sealing and labeling procedures must be followed.
- Maternity cases and prolonged hospitalization require specific considerations in record management.
Record Maintenance Regulations
- HIV diagnoses and other sensitive information must be recorded on designated forms to maintain confidentiality.
- Progress notes for surgical patients are required daily for the first four postoperative days, ensuring continuity of care.
- Detailed records must be maintained for various medical and administrative actions, including lab tests and emergency care documentation.
Key Considerations for Medical Records
- A variety of forms are used in specific scenarios, including for authorization of autopsy (SF 523) and emergency treatment (SF 558).
- Documentation around laboratory tests and radiologic examinations employs forms like SF 546-557.
- Regular reviews and audits of records ensure compliance with standards and accuracy in patient information management.
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Description
Explore the guidelines and procedures for managing medical records in the Navy as outlined in NAVMED P-117 Chapter 16. Understand the importance of primary and secondary medical records, and how they support patient care and provide legal protection. This chapter also highlights the role of BUMED in managing inquiries related to these records.
