The Navy, Marine Corps and any other DoD beneficiaries use the U.S. Navy Medical Outpatient and Dental Treatment Record (NAVMED 6150/21-30) as the official record to document medical and dental evaluations, care, and treatment.
These files hold a lot of medical and legal value to everyone one and the facility involved. The information found here is also used to determine physical fitness and that’s why keeping up with an accurate and updated record is very important in the military.
To learn more about this you can look into the Manual of the Medical Department (MANMED P-117).
How many types of medical records are there?
There are 2 types of medical records. One is called the primary medical records, and the other one is called the secondary medical records.
What is the primary medical records?
The primary medical records are used to document outpatient medical and dental care.
There are three major categories of primary medical records:
- Health records (HRECs)
- Outpatient records (ORECs)
- Inpatient records (IRECs)
It’s also important to note that dental records (DRECs) are part of HRECs (active duty) and ORECs (retirees and family members).
What is the primary’s health records?
The HREC is a record of continuous Care that is given to active duty members. it documents all the outpatient care provided during the member’s career. HREC mainly focuses on documentation of things like ambulatory, but it also branches into inpatient narrative summaries, and operative reports.
What is the primary’s outpatient records?
ORECis a report of continuous Care that mainly focuses on ambulatory treatment for people who are not active duty these are people like retirees, and dependent family members.
What is the primary’s inpatient records?
The IREC documents are provided to a patient who is bedridden at an MTF or ship. These types of records are maintained in HREC (active duty) or OREC (non-active duty).
What is the primary’s dental records?
The DREC is a record of care given to active duty, reservists and families. It basically just contains a record of those dental care files.
What is the secondary medical records?
The secondary medical records are documented by the patient’s specialty healthcare provider. The information found here is usually specific to the provider for a specific need. Secondary medical records are maintained separately from the primary medical records.
Normally temporary and ancillary records are not maintained for active duty personnel except for records dealing with obstetrics and gynecology (OB/GYN), family advocacy, psychology and psychiatry records.
As stated before, primary and secondary medical records are separated. They must follow guidelines established by MANMED. These secondary medical records are usually kept in a specialty clinic or a separate department of MTFs.
What is needed to access the secondary medical record?
If a provider wanted to have access to a secondary medical record, that provider would need to write a note on the DD form 2766, Adult Preventive and Chronic Care Flow Sheet in the primary treatment record.
The information required includes:
- Nature of the secondary record
- Patient’s diagnosis
- Clinic or department name including address and telephone number
After the clinician is done and ready to close the secondary record, a note will also be required to be written on the same form.
Secondary medical records includes:
- Convenience records
- Temporary records
- Ancillary Records
What are the secondary convenience records?
A convenience record is an excerpt from a patient’s primary record and is kept within the MTF by a treating clinic, service, department, or individual provider to allow easy access to the information.
After the provider has used the convenience record and is done with it, they have to purge it from the file.
But before that, they would have to add any medical documentation that they have found from this convenience record that is not already in the primary medical record.
What is a secondary temporary medical record?
A temporary medical record is an original medical record that was created and maintained in a specialty clinic. This is in addition to the patient’s primary medical records.
The purpose of a temporary medical record is to document a current course of treatment. Usually this temporary medical record will become a part of the primary medical record when the course of the treatment is over. One example that is most common is OB/GYN for prenatal patients.
What is a secondary temporary dental record?
Temporary dental records are needed to make sure the timely availability of information. It is supposed to help in the documentation of a current course of treatment for patients being seen in the DTF. one example of this situation is a military member on Temporary Additional Duty (TAD) who does not have his or her dental record and requires emergency dental treatment.
These types of records are maintained by the DTF providing the course of treatment. When the treatment is complete the patient may hand carry the record to the service member custodian of the permanent record. The custodian of the temporary record can also forward it directly to the custodian of the permanent record as well.
There are three minimum forms that the temporary dental record must contain.
- Privacy Act Statement, DD2005
- Dental Health Questionnaire, NAVMED 6600.3
- Dental Treatment Form, EZ603A
Make sure that if a patient is receiving dental treatment and a dental record jacket is not being used, care must be taken to securely fasten any radiographs to the forms comprising the temporary dental record.
What are secondary ancillary records?
The ancillary records have original healthcare documentation that is not in a patient’s primary HREC or OREC.
It is recommended to not place the original file treatment information in the primary treatment record. Place this information into the secondary record to which the patient has limited access to. Examples of such situations include psychiatric treatment or times of real or suspected child or spouse abuse, etc.
How does the Navy use effective records management?
All treatment records belong to the U.S. Government and this record must be maintained by the treatment facility responsible for it.
Ultimately, the responsibility falls upon the Commanding Officer (CO). It’s not actually the duty of the patient to keep and maintain his or her own (health records) HREC, (outpatient records) OREC, or dental records.
Also, the hand-carrying of medical records by unauthorized people such as spouses or siblings of the patient without permission is prohibited.