Part 1. Record of Preventive Medicine and Occupational Health

Part 2. Record of Medical Care and Treatment

Part 3. Physical Qualifications
Part 4. Record of Ancillary Studies, Inpatient Care, and Miscellaneous Forms

HEALTH RECORD FORMS

LEARNING OBJECTIVE: Recall the purpose and completion procedures for the health record forms discussed in this section.

In the last section, you learned there are many medical forms placed in the health record. Also, you learned each form has a specific location within the record. The methods for the management of major areas of health care, both ashore and afloat, are rapidly changing. The Composite Health Care System (CHCS), a secure, computer-based system, is now the primary means that healthcare practitioners use to schedule and process patient visits, track medical results, order labs and x-rays, and process orders for medications. CHCS is especially valuable for pier-side healthcare providers and furnishes a much higher standard for patient care.

Computerized medical documentation (e.g., laboratory test results, emergency room reports, etc.) has become commonplace. However, the Navy Medical Department continues to use many government printed forms (e.g., NAVMED, DD, and SF). This section will cover selected (government- printed) medical forms, their purpose, and procedures for completing them.

Table 12-1.-Sequential List of Health Record Forms

Healthcare providers should enter their signature and identification data in the HREC in black or blue-black ink. Type, print, or stamp provider's name, grade or rating, and social security number below their signature. Stamped facsimile signatures are NOTto be used on any medical form in the HREC. The signing individual assumes responsibility for the correctness of the entry for which they sign.

All medical forms require an accurate and complete documentation of patient identification data. Patient identification data on medical documentation is critical. Complete and accurate documentation of patient identification data helps to ensure the documents are placed in the correct patient's record. Three methods are currently used to place patient identification on medical documents:

embossed medical card,

automated forms, and
handwritten entries.
Embossed medical cards are used to imprint patient identification data on medical forms. Printouts of automated (computerized) forms should provide the information listed in table 12-1. Handwritten patient identification data should be entered in spaces at the bottom of the form. Each method should contain, at a minimum, the patient identification data listed in table 12-2.