Not all physical records can be maintained forever. After long periods of time, these records can become deformed, lost, destroyed, or hard to read.
What to do with lost or destroyed records and forms in the Navy
When an HREC or OREC is lost or destroyed, it’s the duty of the custodian or someone in charge of the records to open a replacement record.
That person will also have to mark the front of the jacket and all lost or replaced forms as “REPLACEMENT.”
The custodian will also have to give a brief explanation of the reason as to why the documents are being replaced or why it was necessary to replace them. The date of when the replacement is created and completed should be entered on the SF 600, Chronological Record of Medical Care.
If in the case that the missing record is found again, it will be combined with the replacement record and placed inside the original record.
What to do when physical record documents deteriorate and become illegible
Physical copies can also deteriorate and become illegible. If this happens to the HREC or OREC, that part should be duplicated. If a duplication is created, the custodian will have to label that duplicated form as “DUPLICATED RECORD” on the font of the jacket above the part that says OUTPATIENT MEDICAL RECORD.
Even if you only duplicate a few forms, make sure to place a big “DUPLICATE” label at the bottom of each form. Don’t forget the add the reasoning as well as the date accomplished on the SF 600.
You can use microfiche for protection and preservation
You can also microfiche all forms that are replaced if that’s still possible. Place this microfiche into an envelope as a permanent part of the record. Write the member’s:
- Full name
- FMP (family member refix)
- Date of birth
- List the original forms contained in the envelope.
If microfilming is not possible and chances are it might not be, just place the original damaged health forms inside a plain envelope for preservation instead. On the front of the envelope, write the patient’s ID data (same as the microfiche envelope).
Mark this envelope as “ORIGINAL MEDICAL RECORDS PERMANENT” and file as the bottommost item in part 2 of the 4-part record jacket.
What does the Navy do with loose health record forms?
When a records custodian finds loose forms, they must find the record that the loose forms belong to. If they can’t find the record, they will have to hold onto this loose form for 1 full year.
After this 1 year period, if the record is still not found, they destroy the forms locally according to paragraph 6 of the standard identification code 6150 contained in SECNAVINST 5212.5 series, Navy and Marine Corps Records Disposition Manual.
How are health and outpatient record forms organized in a record?
When putting together a medical record, the forms must be sorted out in chronological order by date.
The most current document should be on top and the least current documents should be below.
The HREC/OREC have 4 divided parts to it.
|Divided Sections in Health Record
|Record of preventative medicine and occupational health
|Record of medical care and treatment
|Record of ancillary studies, inpatient care, and misc forms