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Medical Education Division |
Operational Medicine 2001
United States Naval Hospital Corpsman 3 & 2 Training Manual
NAVEDTRA 10669-C June 1989
United States Naval Hospital Corpsman 3 & 2 Training Manual
NAVEDTRA 10669-C June 1989
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Hospital Corpsman 3 & 2: June 1989 Chapter 10: Health RecordsNaval Education and Training Command Military Health (Dental) Treatment Record While the personnelman is responsible for the preparation and maintenance of the service record, you, the hospital corpsman, are responsible in the same way for health records. A health record is the official medical and dental history of Navy or Marine Corps personnel and eligible beneficiaries. In this chapter, we will discuss the requirements for opening, closing, verifying, and the custody of the health record. We will also cover the different component health record forms and their sequential placement in the health records. The military health treatment record (medical and dental) is an individual chronological record and a concise summary of all medical and dental examinations, evaluations, and treatments afforded to a member of the Navy or Marine Corps. It provides valuable assistance to Medical Department personnel in conducting examinations, evaluating physical fitness, making diagnoses, and rendering medical or dental care in the treatment of injury or disease. The health record has significant medicolegal value to the member concerned, the member's beneficiaries, and the Government. Proper and equitable determination of claims based upon physical disability is largely dependent upon the information recorded in the health record. Various officials and boards refer to information furnished by the health record in determining physical fitness. It is often the determinant factor in the adjustment of internal revenue assessment and in the establishment of veterans' preference. It affords basic data for the compilation of medical statistics. The dental record is an invaluable aid in the identification of the deceased, especially when other means fail. It is also the source of dental operational readiness data. Accuracy is of utmost importance in the recording of all entries, especially for periods of combat. The inclusion of special examinations, consultations, and laboratory and x-ray reports is vital to an individual's record. If they are not on adjunct health record forms, they should be transcribed into the record to prevent loss of information. The various circumstances under which a health record may be opened, closed, and maintained are described in detail in the Manual of the Medical Department (MANMED), chapter 16. Additional information is presented in the Navy Directives System. Implementation of a new program may require modification of existing regulations to fit the particular need. Therefore, all personnel associated with health record maintenance must keep abreast not only of MANMED but also of all directives to ensure that correct procedures are used. A health record is opened when an individual becomes a member of the naval service, when a member on the retired list is returned to active duty, or when the original record has been lost or destroyed. All applicable spaces on each of the component forms designated for personal identification data will be completed. Official abbreviation of grade or rate will be used. The social security numbers (SSNs) of officers will be followed by the designator code or MOS as appropriate, except on SF 88 (Report of Medical Examination) where the designator code or MOS will follow the grade and component in block 2. All SSNs will be preceded by the family member prefix code. Officers A health record will be opened at the time of acceptance of appointment for individuals appointed from civilian life, and the record will be forwarded to the initial place of active duty. If the member is appointed and retained on inactive duty, the record will be disposed of as follows:
When a midshipman or an enlisted member is appointed to commissioned or warrant grade, the existing health record will be continued in use. The activity having custody of the record at the time of acceptance of appointment will make necessary entries to indicate the new grade and the designator or MOS and prepare summary information entries on SF 600 and NAVMED 6150/4 to include date, place, and grade to which appointed. Health records of civilian candidates selected for appointment to the Naval Academy will be prepared at the Naval Academy at the time of appointment. Health records for civilian applicants selected for an officer candidate program will be opened upon enrollment in the particular program. Enlisted Members The health record will be opened by the activity executing the enlistment contract upon original enlistment in the naval service. However, the health records of members who are enlisted or inducted and ordered to immediate active duty at a recruit training facility will be opened by the Naval Training Center or Marine Corps Recruit Depot, as appropriate. In all cases, the original SF 88 and SF 93 will be attached to the enlistment contract and forwarded with other entrance documents to NAVMILPERSCOM or HQMC. Copies of SFs 88 and 93 will be forwarded to the appropriate training center or recruit depot. These forms with other applicable health record forms will be incorporated into the member's health record. The health records of persons enlisted or reenlisted in a Reserve component and retained on inactive duty will be disposed of as follows:
A member's health record will be closed under the following conditions:
Closing entries will be recorded on NAVMED 6150/4. Entries will include the date of separation, title of servicing activity, and explanatory circumstances as may be indicated. Upon final discharge or death, the medical and dental treatment records will be delivered to the command maintaining the member's service record (no later than the day following separation) for inclusion in and transmittal with the member's service record. In case of death, a copy of the death certificate will accompany the transmitted records. When a member is being separated from the military, he or she should make a copy of the health record to present it to the Veterans Administration for their determination of eligibility for health benefits. The application for benefits is done on VA Form 21-526e, Veterans Application for Compensation. These forms are available at the local Veterans Administration Office. At the very least, the member will be provided with a copy of the separation physical examination recorded on the SF 88 and the most recent Report of Medical History, SF 93. Before forwarding the health record, check each form for accuracy, completeness of name, grade or rate, and SSN. Make sure all health care forms are included. Desertion When a member is officially declared a deserter, an explanatory entry of this fact will be recorded on SF 600 and NAVMED 6150/4. The medical and dental treatment record will be delivered to the commanding officer for inclusion into the member's service record. These records will be retained on board the parent unit (except deployed submarines) for 180 days. On the 18 1st day of absence, the deserter's command will forward the service, pay, and medical and dental records to the Commander, Naval Military Personnel Command. A deserter will be physically examined at the first activity assuming jurisdiction of the member following surrender or apprehension. A statement will be prepared by the medical examiner setting forth the purpose and findings of the examination. A specific opinion about the member's physical fitness for confinement and ability to perform active duty at sea, on foreign service, or in the field, as appropriate, will be recorded on SF 600 for inclusion in the member's health record. Upon apprehension or surrender of a deserter, the commanding officer of the jurisdictional activity will submit a request for the member's records to NAVMILPERSCOM or CMC, as appropriate. A separate request to NAVMEDCOM for the member's health record is not required. Former Members Retained in Naval Hospitals When a patient in a naval hospital is separated from the naval service but retained in the hospital for further treatment and hospitalization, the health record will be closed on the effective date of the separation and forwarded to the command maintaining the member's service record. In such cases, a new health record will not be prepared. However, a copy of the clinical summary, (SF 502 or 539) will be forwarded for inclusion in the health record upon the former member's discharge from the hospital. A copy of a clinical summary prepared incident to the hospitalization of a member whose name is carried on the Temporary Disability Retired List will be forwarded upon termination of hospitalization as follows:
Disenrollment of Midshipmen or NROTC Members When, for any reason, a midshipman's or an NROTC member's affiliation with the naval service is terminated, the member's health record will be closed and retired to National Naval Personnel Records Center (MPR), GSA, St. Louis, MO 63132, in accordance with SECNAVINST 5212.5 series. This will also include midshipmen who graduate from the Naval Academy but do not receive a commission. For midshipmen and NROTC members who retain a status in the naval service after disenrollment, the health record will be forwarded to the member's prospective commanding officer. Verification of the Health Record As a minimum, the health record will be verified annually by medical personnel having custody of the record. When practical, the health record is verified at the same time as the service record and pay record. Verification is also accomplished upon reporting, at the time of physical examination, and upon detachment. The health records of class II Marine Corps reservists are verified at the time of the annual audit of the Ready Reserve. Each record will be carefully reviewed, and any errors or discrepancies noted will be corrected. Special attention will be given to ensure accuracy of the name, SSN, designator or military occupational specialty, date of birth, sex, and grade or rank. Additionally, verify blood group and Rh factor, current immunizations and allergies and record newly acquired marks or scars. Ensure that all required tests have been performed and that all forms are filed in the proper order. All signatures in the health record will be signed in black or blue-black ink. The name and grade or rating of Medical Department officers will be typed, printed, or stamped below their signature. Stamped facsimile signatures will NOT be used on any medical or dental forms of the health record. The signing individual assumes responsibility for the correctness of the entry. If an erroneous entry is noted on review of a health record draw a single diagonal line through it, making sure not to obliterate any part of that entry. An additional entry will be made on an SF 600 showing wherein and to what extent the original entry is erroneous. On the left side of the form containing the erroneous entry, the date of the correcting entry as well as the signature, including grade/rate, of the Medical Department representative making the change will be recorded. If an error is made at the time a handwritten entry is being placed on a health record form, draw a single line through the erroneous word or phrase, put your initials above the error, and continue with the entry. Corrections of typographical or clerical errors (e.g., transposition of numbers or letters) are authorized (fig. 10-1). When the health record is verified during a given year, an SF 600 entry is made and the corresponding year block on the front leaf of the jacket shall be blacked out using a black felt-tip pen. At the end of a calendar year, records that have not been verified during the year can be identified readily and the annual verification accomplished. Treatment records, NAVMED 6150/10-19, and their contents are the property of the Federal Government. The health record is retained in the custody of the medical officer of the ship or station to which the member is assigned. If the ship or station has a dental facility, the dental record is placed in the custody of the dental officer. On ships or stations without a medical officer, the health record may be placed in the custody of the Medical Department representative at the discretion of the commanding officer. When Medical Department personnel are not assigned, the commanding officer may assign custody of the health records to other local representatives of the Medical Department who generally furnish medical support. The custody of treatment records by individuals is absolutely prohibited. Health records are subject to inspection at any time by the commanding officer, superiors in the chain of command, the fleet medical officer, or other duly authorized inspectors. Otherwise, the health record is for official use only, and adequate security and custodial care are required. There are many ideas on the method of adequate security and custodial control. In general, health records should be stored in such a manner as to be inaccessible to the crew or general public. No records or record pages should be left lying around. This also helps to prevent loss or misplacement of records. Medical Department personnel will maintain a Health Records Receipt, File Chargeout, and Disposition Record, NAVMED 6150/7, for each health record in their custody. The completed charge out form shall be retained in the file until the record is returned. Medical officers or Medical Department representatives are responsible for the completeness of required health record entries while the record remains in their custody. Cross-Servicing Health Records The health record of a naval member is serviced by personnel of the Medical Department of the Navy insofar as possible. However, if a naval member is performing an assignment with the Army or the Air Force, or if the medical facilities of either of these only are available, the health record may be serviced by Army or Air Force Medical Department personnel if the attendant service interposes no objection and considers the procedure feasible. Reciprocal procedures for servicing the health records of Army or Air Force personnel by personnel of the Medical Department of the Navy will be maintained whenever feasible and if requested by authorized representatives of those services. Transfers to Ships or Stations When a member is about to be transferred to a deployable unit or command, a medical officer or the Medical Department representative will screen the member's health record to determine if he or she is physically qualified for the assignment. If the member has been delinquent in receiving a current physical examination, or if the member has had a significant illness or injury during the last 12 months, a physical examination will be performed. If the member's physical examinations are current and there is no evidence of significant illness or injury, the medical officer or Medical Department representative may screen the record to certify that the member is qualified for transfer to a deployable unit. This screening will be annotated on an SF 600 and will include:
When a member is to be transferred overseas on an accompanied tour, a physical examination is required to ensure there is no significant illness or injury that adversely impacts on the assignment. Family members will also receive a physical examination. When the member is going overseas on an unaccompanied tour of duty, the family records are to be screened by a medical officer to ensure there is no illness or injury that will require an early return of the member for family health reasons. All screenings will be entered on the SF 600 as well as on the NAVPERS 1300/16, Report of Suitability for Overseas Assignment. The assembled records will be provided to the member or the cognizant personnel officer responsible for the transfer and will include the following additional entries, as applicable:
Lost, Damaged, or Destroyed Records When a health record is lost or destroyed, the custodian will open a replacement health record. The designation REPLACEMENT will be prominently entered on the jacket and all forms replaced. A brief explanation of the circumstances requiring a replacement and the date accomplished will be entered on SF 600. If the missing record is subsequently recovered, the information or entries in the replacement record will be inserted in the original record. Since COMNAVMEDCOM no longer maintains copies of current health records, it cannot furnish replacements for lost or destroyed original records. A health record or any portion thereof will be duplicated whenever it approaches a state of illegibility or deterioration that may endanger its future use or value as a permanent record. The duplicate health record or duplicate portion thereof will be a like reproduction of the original insofar as possible. Particular attention to detail will be used in the actual transcription. When an entire health record is duplicated, the designation DUPLICATE will be prominently entered on the jacket and all forms duplicated. When only component forms are duplicated, they will be individually identified as DUPLICATE. The circumstances necessitating the duplication and the date accomplished will be entered on SF 600. The original health record or any portion replaced by a duplicate will be placed in a plain envelope for protection and preservation and made a permanent part of the health record. On the front of the envelope, record the member's full name, SSN, date of birth, and list of original records contained in the envelope. Mark the envelope "ORIGINAL HEALTH RECORDS-PERMANENT" and file as the bottommost form on the right side of the health record jacket. Hospitalization When a patient is transferred to a naval medical facility, the health record will be delivered with the patient. If the member is admitted to a medical facility while away from his/her command, the health record will be forwarded as soon as practical to the medical facility. Upon discharge from the naval hospital, if the member is directed to proceed home and await final action on the recommended findings of a physical evaluation board, an entry to this effect will be recorded in the health record. Should a member be admitted to a non-Federal medical facility for treatment involving brief periods of hospitalization, the health record will be retained by the activity having custody. If the period of hospitalization exceeds 48 hours or the cognizant activity is a vessel or unit scheduled for deployment, the health record will be forwarded to the cognizant office of medical affairs or to the activity designated by the CMC for Marine Corps members. In those instances where the parent activity retained the health record, a summary of the hospitalization will be entered on SF 600 when the member returns to duty. When a member is hospitalized at a medical facility of a foreign nation, an entry of this fact will be made in the health record. The health record will be retained on board and continued until the patient either returns to duty or is transferred to another U.S. Navy vessel or U.S. military activity. Upon departure of the vessel from the port, the health record will be delivered to the commanding officer for inclusion in the member's service record for forwarding to the nearest U.S. embassy or consulate. Release of Medical Information The Surgeon General (Director, Naval Medicine) has been designated the official responsible for administering and supervising the execution of SECNAVINST 5211.5 series as it pertains to the Health Care Treatment Record System. Additionally, the Surgeon General is the official authorized to deny requests of individuals for notification, access, and amendment to their medical and dental records. Commanding officers and officers in charge of Navy and Marine Corps activities are designated as local systems managers for individual health records maintained and serviced within their activities. Custodians of individual health records are responsible for familiarizing themselves with SECNAVINST 5211.5 series and complying with the provision for preserving the privacy of the information contained in these records. Local systems managers are authorized to release information from health records located within the command if a proper show of authority has been established. The requesting office or individual will be advised that such information is private and must be treated with confidentiality. In all cases where information is disclosed, an entry on the OPNAV Form 5211/9, Record of Disclosure-Privacy Act of 1974, will be made to include the date, nature and purpose of the disclosure, and the name and address of the person or agency receiving the information. Additionally a copy of the disclosure request shall be maintained. The information necessary to accomplish a legitimate purpose or, if required, a complete transcript of an individual's health record may be furnished in accordance with the following policy guidelines:
If the releasing authority is in doubt whether the requesting department has a proper and legitimate need for the information, it will ask the requesting department to specify the purpose for which the information will be used. In appropriate cases, the requesting department will be advised that the information will be withheld until the written consent of the individual concerned is obtained. In honoring proper requests, the releasing authority will disclose only information relative to the request. In the following instances, departments and agencies, both Federal and State, may have a proper and legitimate need for the information:
Commanding officers of Medical Department treatment facilities are authorized to release information from health records located within the command to members of their staff who are conducting research projects. Where possible, the names of parties should be deleted. All other requests from research groups will be forwarded to COMNAVMEDCOM for appropriate action. Release of medical reports or information concerning civilian appointees or employees is controlled by provisions in the Federal Personnel Manual. Attention is invited to pertinent articles in U.S. Navy Regulations (NAVREGS) and the JAG Manual for additional information. Military Health (Medical) Treatment Record Each member's military health (medical) treatment record consists of the NAVMED 6150/10-19, Treatment Record jacket, containing the following health care treatment forms, arranged in top-to-bottom sequence:
Forms g through w are filed in the health record when the procedures are competed in conjunction with outpatient care. No other forms or documents shall be incorporated in the military health (medical) treatment record unless approved by NAVMEDCOM. These may include other SF, DD, and NAVMED forms, as well as forms of other Federal medical facilities documenting health care. Pertinent health care information from local or civilian practitioner forms may be transcribed onto SF 600 for incorporation in the treatment record. Cumulative forms shall be filed in their assigned sequence, with the most recent form placed on top of each previous form. All dates recorded on the component forms of the health record will be entered in the following sequence: day (numeral), month (abbreviated to the first three letter all in capitals), and year (two or four numerals); e.g., 4 JAN 86 or 4 JAN 1986. Military Health (Medical) Treatment Record Jacket (NAVMED 6150/10-19) A new military health (medical) treatment record jacket is prepared when a health record is opened or when the existing jacket has been damaged or is deteriorating to a point of illegibility. The old jacket will be destroyed following replacement. A felt-tip or indelible black-ink pen is used to record all identifying data except the information recorded on the inside of the front leaf. The information in the inside of the front leaf shall be recorded in pencil to permit changes and updating. See figure 10-2, a sample form NAVMED 6150/16, in the preparation of the treatment record jacket. Each treatment record jacket has the second to the last digit of the SSN preprinted on it. The preprinted digit also matches the last digit of the form number (e.g., the preprinted digit on NAVMED 6150/16 is 6). The color of the treatment record jacket corresponds to the preprinted digit as follows:
In preparing a member's treatment record jacket, select a prenumbered NAVMED 6150/10-19 jacket by matching the second to the last number of the member's SSN. Enter the rest of the member's SSN. For members who do not have a SSN (e.g., foreign military personnel), use NAVMED 6150/19 as the treatment record jacket. A "substitute" SSN shall be created for these members by assigning the numbers "9999" as the last four digits of the SSN and assigning the first 5 digits in number sequence (e.g., first SSN 000-01-9999, the second SSN 000-02-9999). Place a piece of black cellophane tape over the number that corresponds to the last digit of the SSN in each of the two number scales. Enter the member's family member prefix code in the two diamonds preceding the SSN. For all Navy and Marine Corps members, the prefix code of 20 shall be entered. A family member prefix code of 00 shall be used for all foreign military personnel. The member's full name (last, first, middle, in that order) is entered in the upper right corner. Indicate no middle name by the abbreviation "NMN. " If the member uses initials instead of first or middle names, show this by enclosing the initials in quotation marks (e.g., "J" "C"). Also, indicate titles, such as JR, SR, and III, at the end of the name. The name may be written on the line provided or be imprinted on a self-adhesive label and attached to the jacket in the patient's identification box. Special categories of records, i.e., personnel in flight status or the Asbestos Medical Surveillance Program, shall be identified by stamping or printing the appropriate entry in the lowest portion of the patient's identification block. Additionally, flag and general officers shall be identified in a like manner." Immediately below the name, indicate in the alert box whether the member has sensitivities or allergies by entering an "X" in the appropriate box. If there are no allergies or sensitivities, leave it blank. To the left of the alert box, indicate the record category by entering an "X" in the box marked "Outpatient (Military Health)." Below the record category box, indicate the member's branch of military service by entering an "X" in the appropriate box. If the individual is not an Army, Navy, Air Force, or Marine Corps member, enter an "X" in the "Other Categories" box and write the individual service on the line provided. The record retirement tape box is to be left blank. Immediately below the retirement year tape box is a similar box that shall be used to indicate the record category. All military (medical) treatment records shall be identified with red tape. The following information will be entered on the inside of the jacket front leaf in pencil to allow for changes:
Record Identifier for Personnel Reliability (NAVPERS 5510/1) The purpose of this form is to readily identify members of the Navy and Marine Corps assigned to the Nuclear Weapons Personnel Reliability Program in accordance with applicable service directives. Medical officers and Medical Department representatives shall familiarize themselves with the Nuclear Weapons Personnel Reliability Manual, NAVMED P-5090, for proper administration of the program. This form is to be retained as the topmost form in the health record at all times. If the member is no longer in the program, remove and destroy NAVPERS 5510/1 and make appropriate explanatory entries on SF 600. Problem Summary List (NAVMED 6150/20) The Problem Summary List list (figure 10-3) contains a summation of relevant problems and medications that significantly affect the patient's health status. Properly maintained, the list facilitates coordinated management of the patient's health condition. Entries on NAVMED 6150/20 should include, but are not limited to, significant medical and surgical conditions, allergies, untoward reactions to medication, and medications currently using or recently used. The problem summary list should be reviewed and revised as necessary at the time of the patient's visit. Chronological Record of Medical Care (SF 600) The chronological Record of Medical Care (figs. 10-4 and 10-4A) provides a current, concise, and comprehensive record of a member's military medical history. Properly maintained, it facilitates the evaluation of a patient's physical condition, reduces correspondence necessary to obtain medical records, eliminates unnecessary repetition of expensive diagnostic procedures, and serves as an invaluable permanent record of medical evaluations and treatments. Entries will be typewritten when practical (except sick call treatment entries which may be handwritten in black or blue-black ink). They will include the date, the name and address of the activity responsible for the entry, and the signature of the responsible medical officer or the Medical Department representative. When a new SF 600 is initiated, the identification block shall be completed with the patient's name, grade or rank, SSN, sex, organization, date of birth, and the name of the organization that maintains the record. SF 600 is continuous and includes the following information as indicated: complaints, duration of illness or injury, physical findings, clinical course, results of laboratory or other special examinations, treatment (including operations), physical fitness at the time of disposition, and disposition. Specific SF 600 entries include, but are not limited to the following:
Whenever a member is evaluated at sick call, an entry will be made on SF 600, reflecting the complaints or conditions presented, pertinent history, treatment rendered, and disposition. Each admission for injury or poisoning is recorded in accordance with BUMEDINST 6300.3 series (Inpatient Data System) and the International Classification of Diseases, Adapted, (ICDA) Vol. 1. Each entry, from admission to final disposition, will be complete with regard to time, date, place, circumstances, diagnosis for which treated, and the signature of the medical officer or Medical Department representative. When a member of the naval service incurs an injury that might result in permanent disability or that results in his or her physical inability to perform duty for a period exceeding 24 hours, an entry will be made concerning line of duty misconduct. Such an entry will include specific facts concerning time, date, place, names of persons involved, and circumstances surrounding the injury. Upon admission of an active-duty member to the sicklist, the medical officer or Medical Department representative will enter whether the disease or injury occurred in the line of duty, and was or was not the result of the patient's own misconduct. (See JAG Manual, chapter VII.) Miscellaneous entries may include the following:
Immunization Record (SF 601) The purpose of this form (figs. 10-7 and 10-7A) is to record information that pertains to prophylactic immunizations; sensitivity tests; reactions to transfusions, drugs, sera, and food; known allergies; blood-typing; and HIV (HTLV III) testing. The recordings will be continued on the current record until additional space is required under any single category. In such cases, a new SF 601 will be inserted and retained with the old SFs 601. Concurrently, a thorough verification of the entries will be made and all immunizations brought up to date. Replacement of the current SF 601 is not required for a change in grade, rating, or status of the member. When the health record is closed, all SFs 601 are forwarded together with other parts of the health record. The name of the medical officer or Medical Department representative administering the immunization or test or determining the nature of the sensitivity reaction will be typed or stamped on the form. Signatures are not required; however, in the event of their use, care should be taken to ensure their legibility. The medical officer or Medical Department representative administering the immunization is responsible for completing all entries in the appropriate sections of SF 601. For specific immunizing agents for smallpox, cholera, and yellow fever, the manufacturer's name and batch or lot number must be recorded. Entries concerning a determined hypersensitivity to a drug or chemical are typed under "Remarks and Recommendations" in capitals (e.g., HYPERSENSITIVY TO ASPIRIN, HYPERSENSITIVE TO LIDOCAINE). This is in addition to a similar entry required on the SF 603 and SF 600, SPECIAL-HYPERSENSITIVITY, retained permanently in the health record. When recording positive results (10 mm or more induration) of the tuberculin skin test (PPD), see BUMEDINST 6224.1 series for current procedures for the Tuberculosis Control Program. When recording the results of the HIV (HTLV III) test, the documentation will include the date drawn, the type of test (ELISA/Western Blot), and the results (positive or negative). All personnel performing international travel under the cognizance of the Department of the Navy will be immunized in accordance with BUMEDINST 6320 series and the current edition of NAVMED P-5052.15A and have in their possession a properly completed and authenticated PHS Form 731, International Certificate of Immunization. Syphilis Record (SF 602) A separate SF 602 (Figs. 10-8 and 10-8A) is prepared upon the occurrence of a syphilitic infection, including any complication or sequela. This record remains a permanent part of the health record until the health record is closed. This procedure is applicable regardless of whether or not more than one SF 602 is required during the member's term of service. An entry will be made of each leutic examination or test conducted and each course of treatment given. Essentially the form is self-explanatory. Abbreviations used in recording treatment should be those officially recognized. Letter designations should not be used for the medications administered. In section I of the form, list all past sexually transmitted diseases, using only the official nomenclature. In section II, the patient signs the form, indicating that he or she understands the nature of the disease and its treatment. Any discussion with patients concerning their condition and health should be accomplished in private, and the information should be considered privileged. Abstract of Service and Medical History (NAVMED 6150/4) This form provides a chronological history of ships and stations to which a member has been assigned for duty and treatment and an abstract of medical history for each admission to the sicklist. A NAVMED 6150/4 (fig. 10-9) is prepared upon opening the health record, and it remains with the health record regardless of any change in the member's status. Continuation sheets are incorporated whenever a current abstract is completely filled. The form is self-explanatory:
NAVMED 6150/4 is retained as a permanent part of the health record until closure of the record. The entry upon closure will indicate date, title of the servicing activity, and explanatory circumstances as may be indicated. Upon discharge and immediate reenlistment, or change in status, an appropriate entry to this effect is made on the current NAVMED 6150/4. Subsequent chronological entries are continued on the same form. Special Duty Medical Abstract (NAVMED 6150/2) The purpose of NAVMED 6150/2 (figs. 10-10 and 10-10A) is to provide a record of physical qualifications, special training, and periodic examinations of members designated for special duty, such as aviation, submarine, and diving. The object of the special duty examination is to select only those individuals who are physically and mentally qualified for such special duty, and to remove from such status those members who have physical or mental defects. Also, special money disbursements are often based upon the determination of a member's physical and mental qualifications or continued requalification for performance of a special duty. Therefore, accuracy of information is essential in reporting information applicable to these categories. This form is opened or prepared initially upon a member's first special duty examination or training. Once it has been activated, it remains an integral part of the health record. Upon a member's discharge and immediate reenlistment, NAVMED 6150.2 is retained in the new health record. Whenever additional space under any category is required, an additional NAVMED 6150/2 is prepared and numbered sequentially, with the most recent on top. Entries are recorded upon completion of each special-duty examination and completion of special training. A hospitalized member is automatically suspended from special duties, and an entry to this effect is made on the form. When a previously qualified member is suspended from special duty or training for physical reasons, the period of suspension and reasons therefore are entered in the appropriate section of the form. The scope of the physical examination and technical training prescribed for these special categories often differs from the general service requirements; therefore, entries reporting results that pertain to these particular examinations or training involved will be approved only by medical officers or specially designated medical service officers who are familiar with their scope and nature (e.g., aerospace physiologists for aerospace physiology training). Record of Occupational Exposure to Ionizing Radiation (DD Form 1141) This form is initiated when military personnel are first exposed to ionizing radiation with the exception of patients incurring such radiation while undergoing diagnostic treatment. Thereafter, it becomes a permanent part of the member's health record. Instructions for preparing DD Form 1141 are on the back of the form. Further instruction concerning the applicability and use of the form and the source of necessary information are contained in the Radiation Health Protection Manual, NAVMED P-5055. Individual Sick Slip (DD Form 689) The purpose of this form (fig. 10-11) is to provide cross-medical service notification of a service member's medical treatment between the medical services of the armed forces. DD Form 689 may also be used to exchange information between the medical officer concerned and the unit commander within the naval establishment. When a member, following treatment, is unable to return to his or her organization either for duty or reporting purposes, use of the form does not preclude the immediate notification of a member's unit commander by telephone or message. This form may be initiated for an individual who has requested or received medical treatment of a sick call nature. It serves as an interim document to furnish information from which subsequent entries are recorded in the health record. It is not prepared when direct cross-servicing of the health record is performed. DD Form 689 is not a record document and should be disposed of as soon as the information is transcribed to the SF 600 except where further use is indicated in connection with line-of-duty determination. Preparation and use of this form is discussed in MANMED, chapter 16. Adjunct Health Records Forms and Reports This section provides instruction for using certain forms in the health record in lieu of transcribing their data to the SF 600, Chronological Record of Medical Care. Narrative Summary (SF 502) The purpose of the SF 502 is to summarize pertinent clinical data relative to treatment received during periods of hospitalization. For all members (officer and enlisted), the original (typewritten) SF 502 is placed in the health record. For officer and enlisted members, entries concerning admissions to the sicklist, showing the nature of the disease, illness or injury, pertinent history or circumstances of occurrence, treatment rendered, and disposition, will be entered on the SF 502. Also indicate whether the disease or injury was or was not suffered in the line of duty and was or was not due to the member's own misconduct. Abbreviated Clinical Record (SF 539) A copy of SF 539 may be filed in the health record when used for active-duty personnel in uncomplicated inpatient care of brief duration (less than 48 hours of hospitalization) and when SF 502 is not otherwise required. However, the information entered on SF 539 must be legible and provide adequate documentation concerning the origin, nature, conduct, status, and aggravation by service, if any, of the condition requiring hospitalization. Consultation Sheet (SF 513) When a report of consultation on an outpatient is recorded on SF 513, it may be incorporated directly into the health record immediately behind the SF 600 or 88 that directs the consult. The SF 513 maybe used by dental officers requesting a medical consultation on a dental patient. The SF 513 is to be included in the member's dental record. If the SF 513 is illegible, transcribe the information to the SF 600. The results of all laboratory examinations performed in conjunction with the consultation are transcribed to the SF 513. Medical Board Report (NAVMED 6100/1) Whenever a member of the naval service is reported on by a medical board, a legible copy of the report shall be placed in the health record in lieu of transcribing the clinical data to the SF 600. A notation is also made on the current SF 600 to indicate that the clinical data is contained in the copy of the Medical Board Report incorporated in the health record. When the Medical Board Report is forwarded to the Navy Department for review and appropriate disposition, a report of the departmental action is entered on the current SF 600. Eyewear Prescription (DD Form 771) The purpose of DD form 771, Eyewear Prescription (fig. 10-12), is to order corrective prescription eyewear and to record information for ordering spectacles. There are three major areas of consideration in completing a DD Form 771: patient information, prescription information, and miscellaneous information. These three critical areas are discussed as follows:
All DD Forms 771 should be typewritten whenever possible. This practice eliminates any errors by misreading an individual's handwriting. Remember, if you are not underway, help is only as far away as your phone. To ensure that the spectacle prescription that the physician has carefully determined to be necessary to satisfy the patient's visual need is provided, it is critical that you, as the corpsman, take the time to correctly order the spectacles. Any omission of information or erroneous information will result in a delay at the fabricating facility or a patient receiving an incorrect pair of spectacles, or both. If individuals requiring spectacles are either without or wearing inappropriate spectacles, they are not going to be as effective as possible. This could have a detrimental effect on the readiness of that individual's command. As a last effort to interpret a prescription that a physician has written, always make a photostatic copy of the prescription and send it to the fabricating facility, rather than try to copy over some information you are unsure of. Make sure that the copy of the prescription is accompanied by a completed DD Form 771. Upon receipt of prescription eyewear from the ophthalmic laboratory, copy 2 of DD Form 771 shall be retained in the member's medical treatment record. Military Health (Dental) Treatment Record Each member's military health (dental) treatment record consists of the NAVMED 6150/10-19, Treatment Record Jacket, containing the following health care treatment forms, arranged in top-to-bottom sequence.
The procedures for opening, closing, and verifying the dental treatment record are the same as the medical treatment record. Military Health (Dental) Treatment Record Jacket (NAVMED 6150/10-19) The dental treatment record jacket (fig. 10-13) shall be prepared in the same manner as the medical treatment record jacket with the exception that an "X" be entered in the record category box marked "DENTAL," and dark blue tape be used in the "Record Category Tape" box. The dental classification box in the top right corner on the jacket back leaf is reserved exclusively for use by dental activities. To facilitate recognition of the four dental classifications of patients, a standard color code, utilizing a strip of appropriately colored cellophane tape shall be placed diagonally across the top right corner. White tape indicates a Dental Class 1- Patients who do not require dental treatment. Green tape indicates a Dental Class 2- Patients who have dental condition that are unlikely to result in a dental emergency within 12 months. Yellow tape indicates a Dental Class 3- Patients who have oral and/or dental conditions that are likely to result in a dental emergency within 12 months. Red tape indicates a Dental Class 4-Patients whose oral classification is unknown because the patient has not received a dental examination in the last 12 months, or the patient's dental record is not held by the responsible Medical Department activity. Health Record-Dental (SF 603) The SF 603 (figs 10-14, 10-14A and 10-14B) provides the following:
An original dental record is prepared:
The SF 603 will accompany Navy and Marine Corps personnel from activity to activity during their entire period of military service. The dental officer will ensure that the Military Health (Dental) Treatment Record with the SF 603/603A, all radiographs, and other pertinent dental records are forwarded to the personnel officer/personnel support detachment for transfer as a unit record with the service record. The SF 603 is brought up to date by entering in section III all dental restorations, any unrecorded dental treatment, and any dental defects discovered (fig. 10-14A). When all the spaces in section III have been filled, an SF 603A, (Dental Continuation) will be used for additional entries (fig. 10-14B). Special Entries on SF 603:
For instructions relative to the recording of dental examination, see MANMED; chapter 6. It is extremely important that the charted record of dental examination be in exact conformity with the provisions set forth in the manual. The Veterans Administration depends on the dental record in determining the claim of a veteran for a service-connected dental disability. Dental Health Questionnaire (NAVMED 6600/3) The Dental Health Questionnaire (fig. 10-15) is self-explanatory. The first part is used to record the patient's chief complaint. The second part is the "Check and Sign" section and is normally completed by the patient. It is a simplified statement of the patient's medical history. All positive responses require explanation, especially the items for "any allergies or sensitivities," "ill effects from injection of Novocaine or Xylocaine," and "heart disease/rheumatic fever/murmur." You must make sure the responses are marked in red in prominent letters across the top of SF 603. Also, on the NAVMED 6150/10-19, the Treatment Record Jacket, immediately below the name, indicate in the alert box whether the member has sensitivities or allergies by entering an "X" in the appropriate box or boxes. The third portion of NAVMED 6600/3 is used to record dental radiographs. The fourth portion is the "Routing/Treatment Plan" and is used to consult with other medical and dental personnel in the facility and to plan a course of examination leading to a diagnosis. The "Patient Identification" section must be completely filled out and updated as necessary.
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