Procedures for outpatient records in the Navy
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What are the procedures for the health outpatient record forms?

What are the different types of medical forms that go into patient health records?

As you already know by now, there are many different types of medical forms that go into a patient’s health records. Fortunately, we have computerized records like lab test results, emergency room reports etc. that have become highly utilized.

Some of the technology we use is CHCS and AHLTA.

Being how these technologies have greatly improved our workflow, we are still using government printed forms like NAVMED, DD, and SF.

What does the provider need to do with all records while in use?

The provider currently managing the records will have to enter their ID and sign the HREC in blue or black ink. They are also going to need to provide their:

  • Name
  • Grade or rating
  • Social security number below their signature (DOD ID may be substituted)

This information can be in the form of typing, printing or a stamp. However, a stamped faxed signature is not acceptable on any medical from in the HREC.

Signing these records assumes responsibility for the correctness and accuracy of the entry.

What type of information must be on medical forms to help identify patients?

It’s extremely important that all the forms have information that can be used to identify the patient. At a minimum, these forms should include:

  • Patient’s FMP and sponsor’s SSN
  • Patient’s full name including the middle initial if possible
  • Sponsor’s branch of service like the Army, Navy, or Air Force
  • Patient’s status like family member or retired

What are the 3 methods that the Navy uses to add patient ID to medical records?

There are 3 methods the Navy uses to add patient’s ID’s on medical documentation:

  • Embossed medical card
  • Automated forms
  • Handwritten entries

By the way, embossed medical cards are used to imprint patient ID data on medical documentations. Automated forms are the same as the printouts from a computer and should have the same information as embossed cards on it. And finally, handwritten data should be filled in the spaces at the bottom of the medical forms.