Health records are verified annually by medical personnel having custody of the record. Health records should also be reviewed when service members report and detach from their command, and at the time of their physical examinations.

Each record should be carefully reviewed, and any errors or discrepancies should be corrected. Items to be reviewed during an annual verification include: form placement, forms order (chronological), and completeness and accuracy of patient identification data on the record jacket and on each piece of medical documentation. In addition, verify that the Privacy Act Statement has been signed, the Summary of Care form is updated (as necessary), blood group and Rh factor are documented, and currency of immunizations and accuracy of allergy documentation are complete.

Upon completion of an annual HREC verification, you should make an SF 600 entry and black-out the corresponding year block on the front leaf of the jacket with a black felt-tip pen. With this procedure, records that have not been verified during the calendar year can be identified readily and the annual verification accomplished.

CLOSING HEALTH RECORDS
LEARNING OBJECTIVE: Recall closing procedures for health records.

A member's health record is to be closed under the following circumstances:

Death or declared death
Discharge
Resignation
Release from active duty
Retirement
Transfer to the Fleet Reserve or release to inactive duty

Missing or missing in action (MIA)(when officially declared as such)
Desertion (when officially declared as such)
Disenrollment as an officer candidate or midshipman

When closing an HREC, make sure the record is in order, that there are no loose papers, and all identification data is consistent. Record closing entry on the NAVMED 6150/4, Abstract of Service and Medical History. Include the date of separation, title of servicing activity, and any explanatory circumstances.

Upon final discharge or death, send the entire HREC and dental record 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. Make sure the original of the separation physical examination documents are included in the HREC before delivery to the command maintaining the member's service record, such as the PSD, PSA, etc. In case of death, send a copy of the death certificate along with the transmitted records.

A copy of the HREC is provided free of charge to members who requests one upon their release, discharge, or retirement.

MISSING OR MISSING-IN-ACTION MEMBERS

Whenever a member disappears and the available information is insufficient to warrant an administrative determination of death, enter a summary of the relevant circumstances on the SF 600. Include circumstances about the presumed disappearance of the individual, then status (missing or missing in action), and supporting documentation. Close the record and handle it as you would records for members being discharged from the service.

DESERTION
When a member is officially declared a deserter, explain this fact on the SF 600 and the NAVMED 6150/4. Deliver member's HRECand dental treatment record to the member's commanding officer (CO) for inclusion in and transmittal with the member's service record for both Navy and Marine Corps personnel. When a deserter is apprehended or surrenders, the CO of the activity having jurisdiction is required to submit a request for the member's records to Bureau of Naval Personnel (BUPERS) or Commandant of the Marine Corps (CMC), as appropriate.

RETIREMENT
When a member of the naval service is placed on the retired list or Fleet Reserve List, close the HREC as you would on a discharge. However, upon request of the retiring member, a new medical record (OREC) is established. A copy of the retiring member's active duty HREC may be incorporated into a new NAVMED 6150/20-29 folder. Make an entry on an SF 600 in the HREC and in the new OREC, stating the date the HREC was closed.

DISABILITY SEPARATION OR RETIREMENT

The MTF should send a copy of the HREC of a member being separated for disability to the DVA (Department of Veteran Affairs) regional officer nearest to where the member will be residing. Send the medical record directly from the MTF to the DVA, so the record can be considered as a primary source of evidence in processing a claim for veteran's benefits. A record carried by the member is considered secondary evidence and is not used to process a claim. Send the record with the VA526, Claim of Benefits, so the regional office can initiate the claim.

Members separating from the service and eligible for veteran's benefits should be provided a copy of their HREC on request. Members should be counseled to request a copy in the event they may make a claim for veteran's benefits in the future. Always offer to send a copy of their HREC to the regional DVAoffice for them.

SUMMARY
As a Hospital Corpsman, you will be responsible for managing health records. Health records are a vital tool in the healthcare delivery process. It is of the utmost importance that you learn and follow guidelines for establishing, handling, maintaining, and closing health records. Keep in mind, your handling of the health record can affect others. Awell-maintained health record furnishes healthcare providers with current medical data, enabling the provider to give each patient timely and comprehensive medical care. Confidential treatment of a patient's medical information honors the patient's privacy and is in keeping with legal regulations. Following the guidelines in this chapter will assist you in properly managing health records under your care.