General Medical Officer (GMO) Manual: Administrative Section

Medical Records

Department of the Navy
Bureau of Medicine and Surgery

The medical records management guidance can be found in the Manual of the Medical Department (MANMED) chapter 16, reference (a). The prior guidance, NAVMEDCOMINST 6150.1, was canceled effective 23 Dec 94.

Updated Outpatient Record

The four-part outpatient record jacket was updated in 1997. The changes to this jacket included an option to use it as the dental outpatient record. This does not mean that the outpatient dental and medical record is to be combined; the medical and dental information will remain separate as always. The jacket is restricted for outpatient use. Inpatient records will continue to use the two-part jacket. There is no deadline to implement the new four-part jacket. The new jacket should be used as personnel change duty stations (PCS), during the annual verification of the active duty record, and when normal wear and tear occur with the record.

Form Sequence and Commonly Used Forms

Article 16-23, pages 16-30, specifically covers the sequence of forms in the four-part jacket. This guide lists, at a minimum, the most commonly used forms and their location in the four-part jacket. Section VII, beginning on pages 16-61 describes commonly used forms and details the minimum requirements to complete them.

Summary of Care Form (SC), NAVMED 6150/20 (1/94)

This form replaces the problem summary list (PSL). This new form will be phased into existing records by replacing older forms which are either filled or worn. PSLs already present in the records will be retained in the records. Do not copy entries from the old form onto the new form. Only current medical problems, chronic or long-term medications, surgical procedures, and other significant health items need to be entered on the new form, in addition to the appropriate items listed in the "Health Maintenance Section" of the new form. A new form, the adult preventive and chronic care flowsheet for implementation of Put Prevention into Practice (PPIP), is currently being tested at Naval Hospital in Camp LeJeune, Jacksonville, and Bremerton. This four-part form will eventually replace the SC as a preventive care flow sheet. The phase in of this form will be similar to the phase in of the SC.

DNA sample filing

See article 16-69, page 16-76.

Family Advocacy, Drug/Alcohol, Medical X-ray Film Jackets

See article 16-29. Requirements are listed for the above named specialty records.

Medical legal Issues

• See article 16-35. This article covers medicolegal, confidentiality, and release of medical information issues associated with medical records.
• Medical records are governed by the Privacy Act of 1974. Transfer of dependent records to a spouse requires approval (signature) of the spouse.
• If you have any further questions regarding medical records management, please contact your command's medical record administrator.

Reference

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