U. S.

ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

FORT SAM HOUSTON, TEXAS 78234

MD0750
INTRODUCTION TO MEDICAL RECORDS
AND THE
PATIENT ADMINISTRATION DIVISION

EDITION 100
 DEVELOPMENT

This subcourse is approved for resident and correspondence course instruction. It reflects the
current thought of the Academy of Health Sciences and conforms to printed Department of the
Army doctrine as closely as currently possible. Development and progress render such doctrine
continuously subject to change.

The contractor responsible for the development of this subcourse was Advanced Development
Group. The instructional systems specialist responsible for overseeing development was Mr.
Richard Smart, DSN 421-9931; commercial (210) 295-9931, and the subject matter expert
responsible for content accuracy was SFC Mark Minter, DSN 471-0944; commercial (210) 221-
0944, COMMANDER, U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL,
DEPARTMENT OF HEALTHCARE OPERATIONS, ATTN: MCCS-HHP, 3151 SCOTT ROAD,
FORT SAM HOUSTON, TX 78234-6100.

ADMINISTRATION

Students who desire credit hours for this correspondence subcourse must meet eligibility
requirements and must enroll through the Nonresident Instruction Branch of the U.S. Army
Medical Department Center and School (AMEDDC&S).

Initial application for enrollment may be made on DA Form 145 or on ATRRS. If DA Form 145 is
used, the approving official must complete the reverse side of the form and forward the form to:
NONRESIDENT INSTRUCTION BRANCH
AMEDDC&S
ATTN: MCCS-HSN
2105 11TH STREET SUITE 4191
FORT SAM HOUSTON TX 78234-6199
or fax the form to 210-221-4012 or DSN 471-4012. A student can self-enroll on ATRRS by going
to website http://atrrs.army.mil and submitting the application under the SELF DEVELOPMENT
selection.

In general, eligible personnel include enlisted personnel of all components of the U.S. Army who
hold an AMEDD MOS (42E, 71G, 76J, and 91-series) or MOS 18D. Officer personnel, members
of other branches of the Armed Forces, and civilian employees will be considered for eligibility
when the application is authenticated by an approving official and when the requested instruction
is job related.

For comments or questions regarding enrollment, student records, or shipments, contact the
Nonresident Instruction Branch at DSN 471-5877, commercial (210) 221-5877, toll-free 1-800-
344-2380; fax: 210-221-4012 or DSN 471-4012, e-mail accp@amedd.army.mil, or write to the
NRIB address given above.

CLARIFICATION OF TRAINING LITERATURE TERMINOLOGY

When used in this publication, words such as "he," "him," "his," and "men" are intended to
include both the masculine and feminine genders, unless specifically stated otherwise or when
obvious in context.
 TABLE OF CONTENTS

Lesson Paragraphs Page

INTRODUCTION…………………………………………. ii

1 INTRODUCTION TO THE HEALTH CARE DELIVERY

SYSTEM…………………………………………………… 1-1--1-3 1-1

Exercises………………………………………………….. 1-13

2 PATIENT ADMINISTRATION DIVISION………………. 2-1--2-5 2-1

Exercises………………………………………………….. 2-13

3 MEDICAL RECORDS AND THEIR USES…………….. 3-1--3-5 3-1

Exercises………………………………………………….. 3-8

EXAMINATION………………………………………………….. EXAM-1

LIST OF ILLUSTRATIONS

Figure Page

1-1 Insignia of the Army Medical Department............................................ 1-9

1-2 Organization chart, The Office of the Surgeon General...................... 1-10
1-3 Organization chart, U.S. Army Medical Command ............................. 1-11
1-4 Typical hospital organization chart ....................................................... 1-12

MD0750 i
 CORRESPONDENCE COURSE OF THE
U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL

SUBCOURSE MD0750

INTRODUCTION TO MEDICAL RECORDS

AND THE PATIENT ADMINISTRATION DIVISION

INTRODUCTION

The Patient Administration Division (PAD) is one of the administrative services

established by the Army Medical Department (AMEDD) to support the health care delivery
mission of medical treatment facilities. Organization of the Army Medical Department; the
Health Care Delivery System; functions and the organizational structure of the Patient
Administration Division; general policies on eligibility; and the purpose, use, and types of
medical records used by the Army are included in this subcourse.

This subcourse will provide an overview of the many facets of medical

recordkeeping, the administrative aspects of support health care, and the functions of the
Office of the Chief, Patient Administration Division. Study of the text will enable you to
familiarize yourself with the general policies and procedures of patient administration.

This subcourse consists of three lessons and an examination. The lessons are:

Lesson 1, Introduction to the Health Care Delivery System.

Lesson 2, Patient Administration Division.

Lesson 3, Medical Records and Their Uses.

Credit Awarded:

Upon successful completion of this subcourse, you will be awarded five credit hours.
You must receive a score of 70 percent or higher on the examination in order to
successfully complete this subcourse.

Materials Furnished:

Materials provided include this booklet, an examination answer sheet, and an

envelope. Answer sheets are not provided for individual lessons in this subcourse
because you are to grade your own lessons. Exercises and solutions for all lessons are
contained in this booklet. You must furnish a #2 pencil.

MD0750 ii
Procedures for Subcourse Completion:

You are encouraged to complete the subcourse lesson by lesson. When you have
completed all of the lessons to your satisfaction, fill out the examination answer sheet and
mail it to the AMEDDC&S along with the Student Comment Sheet in the envelope
provided. Be sure that your name, rank, social security number, and return address are on
all correspondence sent to the AMEDDC&S. You will be notified by return mail of the
examination results. Your grade on the exam will be your rating for the subcourse.

Study Suggestions:

Here are some suggestions that may be helpful to you in completing this subcourse:

--Read and study each lesson carefully.

--Complete the subcourse lesson by lesson. After completing each lesson, work
the exercises at the end of the lesson, marking your answers in this booklet.

--After completing each set of lesson exercises, compare your answers with
those on the solution sheet which follows the exercises. If you have answered
an exercise incorrectly, check the reference cited after the answer on the
solution sheet to determine why your response was not the correct one.

--As you successfully complete each lesson, go on to the next. When you have
completed all of the lessons, complete the examination, marking your answers
in the exam booklet; then, transfer your responses to the examination answer
sheet using a #2 pencil.

Student Comment Sheet:

Be sure to provide us with your observations, comments, and suggestions by filling

out the Student Comment Sheet (found at the back of the exam booklet) and returning it to
us with your examination answer sheet. In this way, you will help us to improve the quality of
this subcourse.

If you wish a personal reply to a question, please call or write your question on a
separate letter (not the student comment sheet). The letter can be sent with the
examination answer sheet. Be sure to include your name, rank, social security number,
mailing address, and subcourse number on your letter.

MD0750 iii
 LESSON ASSIGNMENT

LESSON 1 Introduction to the Health Care Delivery System.

TEXT ASSIGNMENT Paragraphs 1-1 through 1-3.

LESSON OBJECTIVES After completing this lesson, you should be able to:

1-1. Define the mission of the AMEDD.

1-2. Define the responsibilities of the AMEDD

components.

SUGGESTION After completing the assignment, complete the exercises

at the end of this lesson. These exercises will help you
to achieve the lesson objectives.

MD0750 1-1
 LESSON 1

INTRODUCTION TO THE HEALTH CARE DELIVERY SYSTEM

1-1. GENERAL

Patient Administration is designed to provide administrative services to support the

health care delivery mission of an Army medical treatment facility (MTF). This
subcourse will describe the Army health care delivery system, define the mission and
functions of the Patient Administration Division, and introduce medical recordkeeping.

1-2. ORGANIZATION OF THE ARMY MEDICAL DEPARTMENT AND MEDICAL

COMMAND (MEDCOM)

a. Army Medical Department (AMEDD) Organization and Mission.

(1) The Army Medical Department (AMEDD) consists of The Surgeon

General; the Deputy Surgeon General; six officer corps; warrant officers; enlisted
personnel; civilian employees; contracted physicians; and those facilities, supplies, and
equipment which are necessary to carry out its mission and functions. The six corps of
commissioned officers are the Medical Corps (MC), the Dental Corps (DC), the
Veterinary Corps (VC), the Army Nurse Corps (AN), the Medical Service Corps (MS),
and the Army Medical Specialist Corps (SP). The titles of the several corps are
indicative of their professional functions. Army Medical Department insignia are shown
in figure 1-1.

(2) The mission of the Army Medical Department is to maintain the health
of the Army and to conserve its fighting strength. The Army Medical Department has
the responsibility for all medical services which are provided within the Department of
the Army. The Army Medical Department is a completely functionalized, Army-wide
system that includes all services related to the health of the Army and to the care and
treatment of patients. These services include hospitalization, evacuation, dental
service, veterinary service, laboratory service, optometry service, preventive medicine
service, pharmacy service, and medical materiel management and maintenance
services--all of which are interwoven with patient care. The needs of the patient are
paramount.

b. Office of The Surgeon General, Department of the Army.

(1) The Office of The Surgeon General (OTSG) is responsible for the
development, policy direction, organization, and overall management of an integrated
Army-wide health services system. On health and medical matters, including the
utilization of Army Medical Department professional personnel, OTSG has direct access
to the Secretary of the Army and Chief of Staff. In discharging his responsibilities,

MD0750 1-2
equitable consideration is given to the Active Army, Army National Guard, and Army
Reserve.

(2) The Surgeon General (TSG) has Army Staff responsibility for such
matters as:

(a) Planning, developing, programming, directing, and supervising

health services for the Army.

(b) Establishing health standards applicable to personnel of the

Army.

(c) Health profession education and training for the Army.

(d) Medical research, development, test, and evaluation for the

Army and for coordination of the Army-wide program in the biological sciences.

(e) Direction, evaluation, and coordination of medical materiel and

maintenance programs including materiel life cycle management.

(f) Technical review and evaluation of medical and nonmedical

Army materiel to determine possible existence of health hazards.

(g) Formulating policies and regulations concerning the health

aspects of Army environmental programs.

(h) Direction, evaluation, and coordination of worldwide command

programs to protect and enhance health by control of environment and prevention of
disease.

(3) The Surgeon General (TSG) serves as Chief of the Army Medical
Department and commands Army Medical Department personnel, organizations, and
facilities as assigned and exercises technical staff supervision over all other facilities
and units of the Army involved in delivery of health services (see figure 1-2).

(4) Other functions and responsibilities of TSG are listed in AR 10-5,

Organization and Functions, Department of the Army.

c. United States Army Medical Command (MEDCOM). The U.S. Army

Medical Command (MEDCOM) is a major Army command under the jurisdiction of the
Headquarters, Department of the Army, with headquarters at Fort Sam Houston, Texas.

(1) The mission of the Commanding General, Medical Command, is to

provide health services for the Army in the Continental United States (CONUS),
Panama, Puerto Rico, Alaska, Hawaii, Johnston Island, Guam, and Trust Territory of
the Pacific Islands (TTPI); as directed by the Chief of Staff, U.S. Army, for other

MD0750 1-3
departments, agencies, and organizations; to provide medical, veterinary, and dental
professional education and training for Army Medical Department (AMEDD) personnel;
and, as required or directed, of other Army personnel, members of other services or
Federal agencies, and authorized foreign national personnel within policies established
by Headquarters, Department of the Army.

(2) Missions and functions of MEDCOM are performed through:

(a) Medical centers.

(b) Medical department activities.

(c) Medical laboratories.

(d) Regional dental activities.

(e) The environmental hygiene agency.

(f) Optical laboratories.

(g) Authorized field operating agencies.

(h) The Army Medical Department Center and School.

(i) Other medical education and training activities.

(3) Through Army Medical Centers (MEDCENS) and U.S. Army Medical
Department Activities (MEDDACS), the Medical Command (MEDCOM) provides health
care services to eligible beneficiaries under the area support concept.

(4) The Commanding General (CG) MEDCOM is responsible for

providing Army health services to authorized recipients in the United States and its
territories. He also:

(a) Is the principal proponent and developer of concepts, doctrine,

materiel requirements, and organization for the health care system for the Army in field
environments.

(b) Is the provider of the medical professional education and the

systematic, progressive, technical education of Army Medical Department personnel in
the field of health sciences.

(c) Commands the Army's medical centers, hospitals, clinics, and

ancillary medical organizations that provide health services in his area of responsibility.

MD0750 1-4
NOTE: Medical units that are integral to major combat organization, such as divisions,
are not assigned to MEDCOM, but function closely with the MEDCOM system.

(d) Is supporte r of the CG TRADOC in the combat development

process and The Surgeon General in the medical research and development
processes. The organizational chart for the U.S. Army Medical Command is in figure
1-3.

d. United States Army Medical Center (MEDCEN). A MEDCEN is a large

hospital, staffed and equipped to perform the following:

(1) Provide health care for authorized persons. Such care includes a
wide range of specialized and consultative support for all medical facilities within the
assigned geographic area.

(2) Provide specialized medical care to other patients referred to the

MEDCEN by appropriate authority.

(3) Conduct postgraduate education in health professions, when

designated.

(4) Serve as a referral hospital, to include laboratory, for the Medical

Department Activity (MEDDAC) within its Regional Medical Command (RMC).

(5) Conduct professional training programs as specified in its assigned

mission.

(6) Provide administrative and logistical support, as required, to other

units located on the installation for support.

NOTE: See figure 1-4 for typical hospital organizational chart.

e. United States Army Community Hospital (USACH). A USACH is a health

treatment facility which provides definitive inpatient care. It is staffed and equipped to
provide diagnostic and therapeutic services in the field of general medicine and surgery
and preventive medicine services. A USACH may also discharge the functions of a
clinic. When a MEDDAC (discussed below) has a hospital, the USACH is the primary
medical treatment facility of that MEDDAC and is separately identified in the TDA of the
MEDDAC. A USACH may also serve as a specialized treatment or teaching facility
when specified. The organizational structure of a USACH is similar to the hospital in a
MEDCEN.

f. United States Army Medical Department Activity (MEDDAC). A

MEDDAC is an organization encompassing a USACH or designated U.S. Army health
clinic and the associated activities which are responsible for providing health services to
authorized persons within an assigned Health Service Area (HSA). It normally has

MD0750 1-5
command and control over AMEDD facilities, activities, or units (other than TOE units)
located within its HSA. It may also provide administrative and logistical support to other
AMEDD organizations over which it does not exercise command or operational control
such as U.S. Army Medical Laboratories or U.S. Army Dental Activities.

1-3. RESPONSIBILITIES

a. Unit Commander. The unit commander of uniformed services personnel

refers individuals needing medical care to the medical treatment facility that provides
primary health care to the unit. DD Form 689 (Individual Sick Slip) may be used as an
informal memorandum that provides a means of exchanging information between the
unit commander and the attending medical/dental officer. Although "line of duty" is no
longer entered on the form, the information supplied by the unit commander and the
evaluation by the medical/dental officer provide a basis for determination of line of duty.
The form is ordinarily initiated by the unit commander and is hand-carried by the patient,
but it may be initiated by the attending medical/dental officer and sent to the unit
commander when a patient reports directly to the medical treatment facility in
accordance with local procedures or in an emergency. The Individual Sick Slip is not a
permanent record, and it will be destroyed after accomplishing its intended purposes.

b. Medical Treatment Facility Commander. The commander of an Army

MTF, including an Army hospital organized under a Medical Department Activity
(MEDDAC) or an Army medical center, is responsible for determining which persons
within the various categories authorized health care will receive treatment in, be
admitted to, or be dispositioned from the facility. The commander is also responsible for
supervising care and treatment measures so that each patient is provided the best
possible care in keeping with professional standards and the rules of land warfare.
Although authority is delegated to members of the staff who make
decisions pertaining to admissions, treatment measures, and dispositions, the
commander is responsible for interpreting Department of the Army policies for guidance
of staff personnel. One such policy incorporates three requirements for a person's
admission to an Army medical treatment facility:

(1) First and foremost, a physician/dentist on the medical treatment facility

staff must indicate that the patient's condition warrants hospitalization.

(2) The patient seeking admission must be authorized by current

regulations and directives to receive care.

(3) The type of treatment or care required by the patient must also be
authorized by current regulations and directives.

MD0750 1-6
 c. United States Army Community Hospital or Army Medical Center. The
functions of an Army Community hospital are organized into workable groupings that
will best serve professional and administrative requirements.

(1) Professional departments and services. A standard organizational

pattern is provided for an Army Community hospital that is organized as an element of a
Medical Department Activity (MEDDAC) under command of the United States Army
Medical Command in the United States, Puerto Rico, and the Panama Canal Zone.
Hospitals in other areas may follow the same general pattern and modifications are
made in accordance with specific missions and workloads.

(a) Hospital nursing units for inpatient care are divided among the
departments of medicine, surgery, pediatrics, and psychiatry.

(b) Dental clinics and services are provided for inpatients and for
outpatients by The Department of Dentistry.

(c) Inpatient and emergency treatment services are operated by

The Department of Primary Care and Community Medicine.

(d) Other professional services are provided by the departments of

radiology, pathology, nursing, and by the services of social work and of pharmacy.
NOTE: A hospital that is organized as an Army medical center, also under the Medical
Command, has the same professional elements with additional delineations and
departments and services according to workload or according to the necessity for
incorporating functions that are organized separately from the hospital under the
MEDDAC.

(2) Administrative divisions . Administrative functions are grouped as

follows: logistics, information management, resource management, clinical support,
patient administration, personnel, nutrition care, and plans, operations, and training.
The hospital operated as an Army medical center has the same administrative elements
with variations in designations to denote a wider scope of responsibilities or additional
elements that are organized separately from the hospital under the MEDDAC. In both
Army community hospitals and Army medical centers, however, the designations and
scope of functions of the Department of Primary Care and Community Medicine
(professional department) and of The Patient Administration Division are essentially the
same and emphasize the common responsibilities that relate to outpatient and inpatient
administration in any medical treatment facility setting.

d. Outpatient Services. Outpatient services have assumed increasing

workloads as improvements in drugs and treatment measures allow clinic treatment for
patients who formerly required admission to hospitals. Since The Department of
Primary Care and Community Medicine in an Army hospital or medical center operates
emergency treatment and clinic services, most admissions to the hospital are through
these channels. The department prevents unnecessary admissions and reduces the

MD0750 1-7
length of hospitalization through maximum clinic care for patients, and supervises
administrative processing of outpatients. In addition, centralized appointments are often
established to permit effective coordination of patients, health care providers, medical
records, and treatment sites.

e. The Patient Administration Division (PAD). The functions, structure,

responsibilities, and organization of the PAD are covered in detail in Lesson 2.

Continue with Exercises

MD0750 1-8
 Figure 1-1. Insignia of the Army Medical Department.

MD0750 1-9
 Figure 1-2. Organization chart, The Office of the Surgeon General.

MD0750 1-10
 Figure 1-3. Organization Chart, U.S. Army Medical Command

MD0750 1-11
 Figure 1-4. Typical Hospital Organization Chart

MD0750 1-12
EXERCISES, LESSON 1

INSTRUCTIONS. Respond to the following exercises by marking the letter that best
answers the question, or by completing the incomplete statement, or by writing the
answer in the space provided at the end of the question.

After you have completed all the exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly,
reread the material referenced with the solution.

1. Who is responsible for determining which persons within the various

categories of authorized health care will receive treatment in, be admitted to, or be
dispositioned from an Army medical treatment facility?
____________________________________________________________________.

2. List at least eight of the eleven professional departments and/or service in a

U.S. Army community hospital.

a. ____________________________.

b. ____________________________.

c. ____________________________.

d. ____________________________.

e. ____________________________.

f. ____________________________.

g. ____________________________.

h. ____________________________.

3. Who is responsible for the development, policy direction, organization, and

overall management of an integrated Army-wide health services system?
____________________________________________________________________
____________________________________________________________________.

4. ________ ________ are often established to permit effective coordination of

patients, health care providers, medical records, and treatment sites.

MD0750 1-13
 5. List the three requirements for admission to an Army medical treatment
facility.

a. _______________________________________________________.

b. _______________________________________________________.

c. _______________________________________________________.

6. Define a U.S. Army Community Hospital (USACH). ___________________

_____________________________________________________________________
_____________________________________________________________________.

7. A ________________ is considered a large hospital.

8. List the six corps of commissioned officers in the Army Medical Department.

a. ________________.

b. ________________.

c. ________________.

d. ________________.

e. ________________.

f. ________________.

9. Who usually initiates DD Form 689 (Individual Sick Slip)?

_____________________________________________________________________
_____________________________________________________________________.

10. Give two examples of administrative divisions in a U.S. Army community

hospital.

a. ______________________________________________________.

b. ______________________________________________________.

Check Your Answers on Next Page

MD0750 1-14
SOLUTIONS TO EXERCISES, LESSON 1

1. Medical Treatment Facility Commander (para 1-3b)

2. List any eight of the following:

a. Medicine.
b. Surgery.
c. Primary care and community medicine.
d. Radiology.
e. Pathology.
f. Nursing.
g. Social work.
h. Pharmacy.
i. Psychiatry.
j. Neurology.
k. Dentistry. (para 1-3c(1)(a), (b), (c), (d))

3. The Office of The Surgeon General. (para 1-2b)

4. Centralized appointments. (para 1-3d)

5. a. Patient's condition warrants hospitalization.

b. Patient is authorized care in an Army MTF.
c. Type of treatment or care is authorized. (para 1-3b)

6. A health treatment facility which provides definitive inpatient care, and is staffed
and equipped to provide diagnostic and therapeutic services in general medicine,
surgery and preventive medicine services. (para 1-2e)

7. U. S. Army Medical Center (MEDCEN). (para 1-2d)

8. a. Medical Corps.
b. Dental Corps.
c. Veterinary Corps.
d. Medical Service Corps.
e. Army Nurse Corps.
f. Army Medical Specialist Corps. (para 1-2a(1))

9. Unit Commander. (para 1-3a)

MD0750 1-15
10. List any two of the following:

a. Logistics.
b. Patient administration.
c. Personnel.
d. Nutrition care.
e. Plans, operations, and training.
f. Information management.
g. Clinical support.
h. Resource management. (para 1-3c(2))

End of Lesson 1

MD0750 1-16
 LESSON ASSIGNMENT

LESSON 2 Patient Administration Division.

TEXT ASSIGNMENT Paragraphs 2-1 through 2-5.

LESSON OBJECTIVES After completing this lesson, you should be able to:

2-1. Define the mission of the Patient

Administration Division.

2-2. Identify the four branches in the Patient

Administration Division and their functions.

2-3. Identify the management roles of the Chief,

Patient Administration Division.

2-4. Define specific functions of the Patient

Administration Division.

2-5. Define the general policies for eligibility of

health care and programs provided.

SUGGESTION After completing the assignment, complete the

exercises at the end of this lesson. These exercises
will help you to achieve the lesson objectives.

MD0750 2-1
 LESSON 2

PATIENT ADMINISTRATION DIVISION

2-1. MISSION AND GENERAL FUNCTIONS OF THE PATIENT ADMINISTRATION

DIVISION

The mission and general functions of the Patient Administration Division (PAD) are
as follows:

a. To advise the MTP commander and staff on all PAD matters.

b. To provide patient administration services for the medical treatment facility

(MTF).

c. To act as custodian of inpatient treatment records, outpatient treatment records,

and to administratively admit and discharge patients.

d. To provide for inpatient treatment records library service, submission of medical

statistics and other reports, and operation of treasurer functions.

e. To prepare and approve claims for medical services obtained by Army military
personnel from civilian sources.

f. To perform duties of the Physical Evaluation Board Liaison Officer in accordance

with AR 635-40.

g. To provide installation TRICARE advisor services.

h. To process MTF deaths.

i. To ensure and to control confidentiality of medical information.

j. To ensure the movement of patients in need of definitive medical care.

2-2. ORGANIZATION OF THE PATIENT ADMINISTRATION DIVISION

a. Office of the Chief. The Chief, Patient Administration Division, is responsible

for the proper performance of all functions assigned to the PAD. The next paragraph will
address the organization and specific functions of the Office of the Chief.

MD0750 2-2
 b. Patient Accountability Branch. Functions include:

(1) Admissions and dispositions. This office is open 24 hours daily for
administrative admission and disposition of patients.

(2) Evacuation and transfer. Provides for transfer, movement, receiving and
pickup of patients to and between MTFs.

(3) Performing all DEERS eligibility inquiries as required in accordance with

DOD regulations and instructions, when not provided automatically through the Composite
Health Care System (CHCS).

(4) Managing and controlling eligibility inquiries for the MEDCEN / MEDDAC /
DENTAC in accordance with DOD regulations and instructions.

(5) Verification of eligibility of care.

(6) Operation of a Medical Services Account. Responsible for collecting and

accounting for services provided in the facility, e.g., medical bills and dining facility
monies.

(7) Operation of a central clearance activity for all patients being dispositioned
and for those military patients departing on an interim basis.

(8) Coordination of administrative support for active duty personnel absent sick
in nonmilitary MTFs.

(9) Operation of the Patients' Trust Fund.

(10) Operation of the Patients' Clothing and Baggage Section when authorized
by the commander.

(11) Operation of the Hospital Information Activity when directed by the

commander. Usually, this section is placed in the Office of the Information Management
Division.

c. Medical Records Administration Branch. Functions include:

(1) Medical records administration consultation for the management of all

inpatient records.

(2) Conducting MTF-wide medical records training programs.

(3) Custodianship of inpatient medical records.

MD0750 2-3
 (4) Receipt, processing, filing, and disposition of inpatient medical records.

(5) Management of the Individual Patient Data System (IPDS), to include

coordinating use of output reports in the MTF and reviewing reports for trends.

(6) Maintenance of inpatient accountability data and reports for the Inpatient
Accounting System in hospitals authorized this system.

(7) Coordination of medical statistical reporting and the submission of required

reports.

(8) Maintenance of required medical reference indexes.

(9) Assistance to the professional staff in clinical research projects.

(10) Guidance to the staff on patient administration aspects of JCAHO

accreditation. The branch functions as the PAD coordinator for the medical care
evaluation program and utilization review program and supervises the documentation
review of all medical records.

(11) Coordination with the Staff Judge Advocate (SJA) on medico-legal

aspects of medical record documentation, the release of medical information, and consent
for care requirements or procedures, and advising MTF staff on these matters.

(12) Release or transmittal of all requested medical records, medical

statements, or information from medical records, and the initiation of fee collections as
necessary. Obtains requested medical records from MTFs or other sources.

(13) Operation of the central medical transcription service if a central system is

established by the commander.

d. Patient Affairs Branch. Functions include:

(1) Administrative management of Reserve and National Guard personnel

requiring medical care. This involves coordinating treatment in Uniformed Services or
other Federal MTFs or from civilian sources; requesting extensions of active duty for
training (ADT) or full-time training duty (FTTD) orders; coordinating follow-up care; and
administering medical boards and physical disability processing.

(2) Serving as the central office for medical board administration.

(3) Performing physical Evaluation Board Liaison Officer (PEBLO) services.

MD0750 2-4
 (4) Maintenance of long term patient rosters to project patient disposition in
coordination with other staff elements.

(5) Coordination of Temporary Disability Retired List (TDRL) examinations.

(6) Administrative management of very seriously ill, seriously ill (VSI/SI), and
special category patient (SPECAT) reporting requirements.

(7) Preparation of certificates of birth.

(8) Initiation of Line of Duty determinations and coordination of any follow-up.

(9) Third-party liability reporting to the recovery judge advocate (RJA).

(10) Coordination of the Ancillary Medical Services Program, if operated, under

provisions of AR 40-3.

NOTE: These services are provided retired members and family members who are
receiving care from civilian sources.

(11) Decedent affairs services including:

(a) Preparation of certificates of death.

(b) Coordination of notifications.

(c) Coordination of the disposition of remains with appropriate authorities.

(d) Coordination for services under the Survivors' Assistance Program for
eligible next-of-kin (NOK).

e. Outpatient Medical Records Branch. Functions include:

(1) Management of health record (HREC) and outpatient treatment records

(OTR) operations in the hospital and in all TMC/health clinics functioning as elements of the
installation-wide Primary Care and Community Medicine Services.

(2) Technical assistance in medical records management for clinics at other

installations in the HSA.

(3) Preparation of patient recording cards for all patients.

(4) Operation of a records control program to assure the delivery, return, and
follow-up of records removed from the records room.

MD0750 2-5
 (5) Coordination with military personnel support activities on matters pertaining
to HREC processing for incoming and departing members and periodic HREC
inventories.

(6) Coordination with the professional staff on the screening of incoming

HRECs.

(7) Specialized management of those records containing sensitive medical

data or for personnel in special category programs; e.g., the Personnel Reliability
Program.

(8) Performing quality management review of HRECs and OTRs to ensure

compliance with existing regulations and guidelines.

(9) Assistance to the Medical Records Administration Branch in coordinating

support of ambulatory medical care evaluation and documentation review of HRECs and
OTRs.

(10) Management of civilian employee outpatient medical records when not

accomplished by an occupational health clinic (OHC). Technical assistance is provided
when the records are maintained by the OHC.

(11) Assistance to the Medical Service Accountable Officer (MSAO) in initiating

outpatient care payment or reimbursement as appropriate.

2-3. ORGANIZATION AND FUNCTIONS OF THE OFFICE OF THE CHIEF

a. The Office of the Chief, Patient Administration Division (PAD), consists of the
Chief, an NCOIC, and a secretary. If the medical treatment facility is large, an assistant
chief may be included in the organization.

(1) The two major management roles of the Chief are:

(a) Principal advisor to the MTF commander and staff on patient

administration matters. Serves in a staff position for the commander in this role.

(b) Manager of the Patient Administration Division.

(2) The NCOIC is the office manager for the Chief. As such, the NCOIC
coordinates office management throughout the PAD. The NCOIC is responsible for
ensuring all Army directives are current, that all equipment and supplies necessary to
operate the PAD are available, and other administrative functions as needed. The NCOIC
is also responsible for the master files of PAD reports.

MD0750 2-6
 (3) The secretary handles the administrative duties of the office.

b. One of the functions of the Chief is planning, controlling, and coordinating the
overall operation of the Division and all subordinate organizational components. This
includes:

(1) Selecting branch NCOICs, conducting staff meetings, reviewing operating

procedures used by the various branches, and other administrative management of the
staff.

(2) Working with the staff to improve timeliness of reports and filing of records
as well as the implementation of new directives and new computer technologies related to
medical records.

(3) Monitoring the quality of medical records generated by the MTF for
compliance with requirements of the Joint Commission on Accreditation of Hospital
Organizations (JCAHO) and other regulatory directives through comprehensive records
review and audits by the medical records staff.

(4) Being the custodian of all medical records thereby ensuring confidentiality,
the safety of control mechanisms, accuracy, and timely filing. (The hospital commander
usually delegates this duty to the Chief.)

(5) Developing procedures for the MTF Administrative Officer of the Day (AOD).
Eighty to 90 percent of the AOD functions are related to patient administration procedures.

c. A further function of the Chief is maintaining close liaison with the Deputy
Commander for Clinical Services (DCCS), chiefs of departments and services, health care
providers, and chiefs of administrative divisions and offices to ensure prompt decisions on
matters pertaining to patient administration. This includes:

(1) Serving on various hospital committees such as the Quality Assurance

Committee, Executive Committee, Ambulatory Care Committee, Health Consumer
Committee, Risk Management Committee, Patient Care Assessment Committee, and
others as assigned.

(2) Providing administration and counseling for physical disability processing

and the administrative matters relating to medical board/physical evaluation board actions.

(3) Resolving or assisting in resolving problems relating to patient

administration.

(4) Serving as a liaison with physicians on medical records and administrative

reports such as VSI/SI and casualty reports.

MD0750 2-7
 (5) Advising unit commander on profiling.

(6) Working with the legal office on the legal aspects of medical records.

d. Another very important function of the Chief is to advise the commander on

patient administration matters. This includes:

(1) Meeting with the MTF commander at morning staff meetings and providing
pertinent information on patients or other problems.

(2) Advising the commander on matters related to Congressional inquiries and

Inspector General inquiries.

e. Another function is planning and conducting training programs for the division.
Training includes:

(1) SDT training.

(2) Training new employees.

(3) Inservice training for new procedures.

(4) New directives and computer technologies.

(5) Training new physicians and nurses on administrative requirements by PAD

in the MTF organization.

(6) Cross-training of personnel to maximize PAD staff utilization.

f. Other functions include: signing reports and correspondence pertaining to the

Division as required; establishing priorities for aeromedical evacuation of patients; serving
as the alternate PEBLO; providing TRICARE advice services; monitoring outlying clinics;
verifying that individual patients are eligible for Supplemental Care and providing patient
care assistance when needed.

2-4. SPECIFIC FUNCTIONS OF THE PATIENT ADMINISTRATION DIVISION

a. Release of Medical Information. The release of medical information is

regulated by the Privacy Act of 1974, the Freedom of Information Act, AR 340-17, and AR
340-21. One of the purposes of the Privacy Act is to provide certain safeguards for an
individual against an invasion of personal privacy by the unauthorized collection of
information by the Federal Government and the misuse of that information contained in
Federal Government records. While the Freedom of Information Act allows the public to
obtain certain types of information from the Government, it provides exemption from public

MD0750 2-8
disclosure for certain categories of information on individuals when disclosure may
constitute a clearly unwarranted invasion of personal privacy. Medical information may be
released under certain conditions, but the individual is protected from unauthorized use by
official or unofficial requests.

b. Disclosure. Medical information may be disclosed under certain

circumstances. All requests for medical information are handled by the patient
administrator or his designee. Army personnel seeking medical information about a
patient must request it in writing from the MTF commander, using DA Form 4254-R
(Request for Private Medical Information). They must state their need, citing the authority
supporting the need, and present their official credentials. Authorization for unofficial
requests must also be in writing. Unofficial requests require DA Form 5006-R
(Authorization for Disclosure of Information). The form must be signed and dated by the
patient.

c. Line of Duty (LD). Line of Duty investigations are required to ascertain the
circumstances under which a disease, injury, or death has occurred for active, Reserve and
National Guard members. The individual's LD status at the time of disease, injury, or death
determines the administrative course of action taken by the Government. For example,
Title 10 USC requires that an officer forfeit pay under certain circumstances, and an
enlisted member with an unfavorable LD make up lost time or forfeit pay while hospitalized
or away from duty. Enlisted promotions and posthumous appointments are also affected
by unfavorable LD findings. Of more importance are the far-reaching implications of Line
of Duty. Entitlement to benefits provided members or their survivors by the Secretary of the
Army, the Veterans Administration, and other Government agencies can also be affected
by unfavorable LD findings.

d. Medical Regulating. Medical Regulating involves evacuation and transfer of

patients. There are many reasons for moving patients from one MTF to another while the
patient is under medical control. For the most part, these reasons fall into one or more of
the following general categories:

(1) Medical. All uniformed services hospitals are not identical in capability or
facilities. An MTF may have to transfer a patient to another MTF that has the capability to
provide the necessary treatment. The determination to move a patient for medical reasons
is made by the attending physician with the approval of the hospital commander.

(2) Administrative. A patient may need to be transferred for the benefit of the
government rather than for purely medical reasons. A member who is being considered for
separation or retirement due to his medical condition may be transferred to the MTF
nearest the Physical Evaluation Board. Prior to moving a patient for administrative
reasons, the hospital must obtain approval from the Medical Command (MEDCOM).

MD0750 2-9
 (3) Compassionate/personal. Transfers for compassionate or personal
reasons are normally patient-generated. A member who incurs an injury or disease which
will require an extended period of hospitalization may be transferred to a location near his
home if the physician feels it is in the best interest of the patient. This type of transfer also
requires approval from the MEDCOM.

e. Third Party Liability. The Medical Care Recovery Act requires the government
to recover from a third person the reasonable cost of care provided to an individual for
injury resulting from negligent liability by another person. AR 40-16 establishes procedures
for notifying the Recovery Judge Advocate when care is provided an individual who has
been injured due to possible negligence. These procedures ensure that collection action
be initiated to recover the value of all treatment provided from the third party responsible for
the injury.

f. Disposition of the Deceased. Mortuary benefits are provided for active duty
military members when deceased. AR 600-8-1 defines the extent of these benefits.
Next-of-kin notification responsibilities rest with the Casualty Area Commander, or senior
Army representative. Certain medical records are prepared including Hospital Report of
Death (DA Form 3894), Certificate of Death, and Authorization for Autopsy (SF 523), etc.

g. Very Seriously Ill/Seriously Ill (VSI/SI). The purpose of preparing VSI/SI

reports is to maintain records of very seriously ill or seriously ill cases. The reports also
provide instructions for notifying next-of-kin or other authorized persons of the condition of
the patient. The following definitions are to applied literally:

(1) A patient is very seriously ill when his illness is of such severity that life is
imminently endangered.

(2) A patient is seriously ill when his illness is of such severity that there is cause
for immediate concern but there is no imminent danger to life.

h. Medical Boards and Physical Profiling. Medical boards are an instrument of

the Army Medical Department appointed by the commander of a medical treatment facility
to assist in determining the disposition of those patients for whom medical board action is
required by higher authority and in other cases deemed advisable. Medical board action
is required when a soldier has incurred either a permanent or temporary disability.

(1) Physical Evaluation Board (PEB) This board processes patients in

determining retention, disability, retirement, or separation. All medical and profiling boards
rely heavily upon the soldier's medical records.

(2) Physical Profile System. This system classifies individuals according to

their functional ability.

MD0750 2-10
 i. Quality Assurance. Quality assurance is a facility function under the Deputy
Commander for Clinical Services. However, the Army Quality Assurance Program (QAP)
evaluates medical care. It provides for a continuing assessment of the appropriateness of
patient care. The overall objective of the medical care evaluation plan is the maintenance
of high quality patient care and the effective utilization of hospital services and resources.
Assessment and evaluation are an ongoing process. Standards of patient care are
established by the Joint Commission on Accreditation of Hospital Organizations (JCAH0).
These standards provide the basis against which medical care evaluation is made.
Medical care evaluation is concerned with two dimensions:

(1) Quality of care which includes medical audit and credentialing.

(2) Utilization review which relates to the ongoing evaluation of health resources
management.

j. Regulations, Procedures, and Forms. Information and instruction regarding

regulations, procedures, and forms used for these administrative actions is presented in
subsequent subcourses.

2-5. ELIGIBILITY FOR HEALTH CARE

a. Primary Mission. In support of the Army Medical Department's mission, an

Army medical treatment facility (MTF) must provide medical treatment to members of the
uniformed services on active duty or active duty for training, including foreign
military members entitled to health care in United States military facilities. This primary
mission extends to retired members on the Temporary Disability Retired List (TDRL) who
are required to undergo periodic examinations and who may need hospitalization in
connection with such examinations.

b. Space Availability. For other categories, hospital admission and medical

treatment depend upon availability of space, and facilities, and the capabilities of the
professional staff to provide care based on the following considerations: primary mission,
adequacy of professional care available, the number of patients who may be treated
without sacrificing high professional standards, and optimum use of facilities.

c. Persons Authorized Care in an Army MTF. With some exceptions, the

following are authorized care in order of sequence.

(1) Members of the uniformed services (Army, Navy, Marine Corps, Air Force,
Coast Guard) on active duty.

(2) Members of the Reserve component on active duty for training.

MD0750 2-11
 (3) Members of the Reserve component on inactive duty for disease or injury
that occurred at or during training.

(4) Family members of active duty.

(5) Members retired for length of service or physical disability.

(6) Family members of deceased and retired members.

(7) Others as outlined in AR 40-3.

d. Uniformed Services Health Benefits Program (USHBP). USHBP covers

two programs which are distinguished by the type of facility which provides the care.

(1) Uniformed services health care provided at uniformed services medical

treatment facilities, supplemented by care from civilian sources.

(2) Civilian Health and Medical Program of the Uniformed Services

(CHAMPUS).

(a) Health care provided by civilian sources or in civilian medical treatment

facilities to CHAMPUS beneficiaries.

(b) Medical care is cost-shared by the government and the patient.

e. Identification. The basic determinant of eligibility for health care is the

identification card. Eligible personnel are also required to enroll in the Defense Enrollment
Eligibility Reporting System (DEERS). While determination of eligibility is the
responsibility of the medical treatment facility commander in accordance with AR 40-3,
PAD personnel are called upon daily to advise the commander of current regulations and
policies. When proper identification is not available and no emergency exists, a statement
from the sponsor, parent, or guardian may be accepted. The statement must explain why
the person does not have proper identification and why the patient is not enrolled in
DEERS. More information on eligibility for care under the Uniformed Services Health
Benefits Program is provided in a later subcourse.

Continue with Exercises

MD0750 2-12
EXERCISES, LESSON 2

INSTRUCTIONS. The following exercises are to be answered by marking the lettered

response that best answers the question, or by completing the incomplete statement, or by
writing the answer in the space provided at the end of the question.

After you have completed all the exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers. For each exercise answered incorrectly, reread
the material referenced with the solution.

1. Who is responsible for the master files of the Patient Administration Division?

____________________________________________________________.

2. List the five functions of the Chief, Patient Administration Division.

a. _______________________________________________________.

b. _______________________________________________________.

c. _______________________________________________________.

d. _______________________________________________________.

e. _______________________________________________________.

3. List the six hospital committees on which the Chief, Patient Administration
Division may serve.

a. _______________________________________________________.

b. _______________________________________________________.

c. _______________________________________________________.

d. _______________________________________________________.

e. _______________________________________________________.

f. _______________________________________________________.

MD0750 2-13
 4. Who acts as custodian of inpatient treatment records, outpatient treatment
records, and administratively admits and discharges patients?

__________________________________________________________________.

5. What are the two major management roles of the Chief, Patient Administration
Division?

a. _______________________________________________________.

b. _______________________________________________________.

6. Using the following list of authorized personnel, select the usual sequence of
priority for medical care in an Army MTF.

a. Mr. Lendon, retired MAJ.

b. Mrs. Janes, dependent wife.

c. SGT Stevens, active duty Army.

d. CPT Kipler, U.S. Army Reserve, on active duty for training.

7. __________ __________ __________ is a system which classifies individuals

according to their functional ability.

MD0750 2-14
Items 8 through 16. Match Column A with Column B by selecting the correct PAD Branch
listed in Column B to its responsible function listed in Column A. Place your answer (a
through d) in the spaces provided in Column A.

Column A Column B

___ 8. Prepares certificates of death. a. Patients Affairs Branch.

___ 9. Prepares patient recording cards. b. Patient Accountability

Branch.
___ 10.Prepares certificates of birth.
c. Outpatient Medical Records
___ 11.Operation of Patient Trust Fund. Branch.

___ 12.Administrative support for absent d. Medical Records

sick active duty personnel. Administration Branch.

___ 13.Specialized management of records

containing sensitive medical data.

___ 14.Conducts MTF-wide medical records

training program.

___ 15.Coordination of medical statistical

reporting.

___ 16.Management of activity for receiving,

evacuating, transferring, and referring
patients to and between MTF.

Check Your Answers on Next Page

MD0750 2-15
SOLUTIONS TO EXERCISES, LESSON 2

1. NCOIC. (para 2-3a(2))

2. a. Planning, controlling, and coordinating overall operation of the division and

all subordinate organizational component.
b. Maintaining close liaison with other elements in the MTF.
c. Advising the commander.
d. Planning and conducting training.
e. Signing reports and correspondence. (para 2-3b, c, d, e, f)

3. a. Quality Assurance Committee.

b. Executive Committee.
c. Ambulatory Care Committee.
d. Risk Management Committee.
e. Health Consumer Committee.
f. Patient Care Assessment Committee.
g. Others as assigned. (para 2-3c(1))

4. Patient Administration Division. (para 2-1(b))

5. a. Principle advisor to MTF commander and staff on patient administration

matters.
b. Manager of the Patient Administration Division. (para 2-3a(1))

6. c, d, b, a. (para 2-5c)

7. Physical Profile System. (para 2-4i(2))

8. a (para 2-2d(11))

9. c (para 2-2e(4))

10. a (para 2-2d(7))

11. b (para 2-2b(7))

12. b (para 2-2b(5))

13. c (para 2-2e(8))

14. d (para 2-2c(2))

15. d (para 2-2c(7))

MD0750 2-16
16. b (para 2-2b(2))

End of Lesson 2

MD0750 2-17
 LESSON ASSIGNMENT

LESSON 3 Medical Records and Their Uses.

TEXT ASSIGNMENT Paragraphs 3-1 through 3-5.

LESSON OBJECTIVES After completing this lesson, you should be able to:

3-1. Define a medical record and related terms.

3-2. Identify the status, purposes, and characteristics of

medical records, and the patient categories for whom the
medical record is prepared.

3-3. Identify the forms used as file folders for medical

records or for recording medical care.

SUGGESTION After completing the assignment, complete the exercises

at the end of this lesson. These exercises will help you
to achieve the lesson objectives.

MD0750 3-1
 LESSON 3

MEDICAL RECORDS AND THEIR USES

3-1. OBJECTIVE

Medical records and patient administration procedures support the Army Medical
Department's mission to maintain the health of the Army and preserve its fighting
strength. These procedures are based on law, Department of Defense policies, and
international agreements. They are in accord with professional standards and
functional responsibilities for patient care. Personnel of an Army medical treatment
facility must determine the eligibility of persons to receive Army medical services. Next,
they must select and prepare proper medical record forms and send notifications about
casualties. This includes providing information and assistance to the next of kin of
military members who are very seriously ill or seriously ill, injured as the result of hostile
action, or dead.

3-2. EXPLANATION OF TERMS

a. Medical Record. A medical record is any military or civilian document that

gives information on the evaluation, findings, diagnosis, and treatment of a patient.
Included as medical records are the Health Record, Outpatient Treatment Record,
Inpatient Treatment Record, and U.S. Field Medical Card (FMC). Paramedical
documents, such as X-rays and immunization registers, are not considered medical
records even though kept in the same file with other medical records.

b. Health Record (HREC). An HREC is a permanent, continuous, locally

available file used to record medical information, both health and dental, for military
personnel. It is also used for military prisoners and U.S. Military Academy cadets.

c. Outpatient Treatment Record (OTR). An OTR is the outpatient treatment

and dental records of a patient for whom an HREC is not kept, e.g., family members,
retirees, civilian emergencies.

d. Inpatient Treatment Record (ITR). An ITR is the record prepared by an

MTF with authorized beds for inpatient medical care (hospital, convalescent center, or
fixed troop/health clinic) for any patient admitted for medical or dental care. It is initiated
on admission to the MTF and completed at the end of hospitalization. This record
applies to all patient categories.

e. U.S. Field Medical Card (FMC). An FMC is a medical record used by aid
stations, clearing stations, and nonfixed troop or health clinics operating overseas, on
maneuvers, or attached to commands moving between stations.

MD0750 3-2
3-3. STATUS OF MEDICAL RECORDS

a. Medical Records Are Private. Medical information contained in the record is

private and belongs only to the patient. Such information, if divulged, may cause
personal embarrassment or harm and should not be open to public scrutiny.

b. Medical Records Are Confidential. Confidentiality means guarding the

privacy of medical information. Information gained through the examination or
treatment of a patient is confidential. Medical confidentiality is not a security
classification of CONFIDENTIAL. Department of the Army (DA) policy states that
medical confidentiality for all patients will be protected as fully as possible.

c. Medical Record Ownership. Army medical records are the property of the
government. The same controls that apply to other government documents apply to
medical records. AR 40-66 explains Department of the Army policy and procedures on
the confidentiality of private medical information.

d. Responsibilities. Persons and agencies within the Department of the Army

who use medical information for official purposes are responsible for protecting the
privacy and confidentiality of that information. The MTF commander is responsible for
issuing local rules to enforce the policies and procedures stated in AR 40-66 on
confidentiality of medical information.

3-4. PURPOSES OF MEDICAL RECORDS

a. The first purpose of medical records is to provide a record of patient care and
treatment. Medical records should provide a clear, concise, comprehensive, and
complete medical history of patient care and treatment for an individual.

b. The second purpose of medical records is to plan patient care. A plan will
promote more efficient care, will minimize duplication of effort, and minimize repetition
of diagnostic procedures.

c. A third purpose of medical records is to provide a means of communication.

Medical records serve as a communication device between physicians and other
professional personnel. They reduce correspondence to obtain records of previous
treatments in some cases and can be used as the communication device for patient
evacuation to another MTF. Effective communication through medical records provides
continuity of care for the patient.

d. Fourth, medical records protect the interests of both the patient and the
government. Medical records are used to evaluate the quality of patient care. They
provide an audit trail on the accuracy, timeliness, completeness, clinical pertinence, and
adequacy of medical care, thus protecting the legal rights of the patient. Complete and
accurate medical records also protect the legal rights of the government by providing
documented information on the care given to patients.

MD0750 3-3
 e. The fifth purpose of medical records is to provide documentation for hospital
accreditation. The Joint Commission for Accreditation of Hospital Organizations
(JCAHO) has established standards for patient care throughout medical treatment
facilities. Hospitals must provide evidence of the extent of its compliance with each
standard that is applicable to its operation. To be accredited, a medical treatment
facility must demonstrate it is in substantial compliance with the standards. Medical
records are used to show compliance in patient care. After surveying an MTF, the
JCAHO may make recommendations on upgrading medical records and/or procedures.

f. Medical records also provide data for medical research.

3-5. TYPES OF MEDICAL RECORDS AND FOR WHOM THEY ARE PREPARED

a. Health Record (HREC).

(1) Description. The health record is a permanent, continuous file. The

records kept in this file are prepared as the member receives medical and dental care.

(2) Forms. DA Forms 3444 or 8005 series can be used as file folders for
health records.

(3) Purposes unique to HRECs.

(a) HRECs help medical officers advise commanders on retaining and

using their personnel.

(b) HRECs help physical evaluation boards appraise the physical fitness
of Army members and their eligibility for benefits.

(c) HRECs accelerate mobilization of U.S. Army Reserve (USAR) and

Army National Guard (ARNG) personnel.

(4) Patient categories for whom the HREC is prepared. AR 40-66 identifies
those patient categories for whom the health record is prepared as:

(a) All active duty personnel (Army, Navy, Marine, and Air Force).

(b) Reserve components (USAR and ARNG) personnel.

(c) Cadets of United States Military Academies.

(d) Military prisoners while in confinement.

MD0750 3-4
 b. Outpatient Treatment Record (OTR).

(1) Description. A record prepared for each nonmilitary patient treated as an

outpatient at a U.S. Army medical facility for whom the Army health record is not
required.

(2) Forms. DA Forms 3444 or 8005 series are used as file folders for
outpatient treatment records.

(3) Characteristics unique to the OTR.

(a) OTRs are not permanent.

(b) OTRs are not necessarily continuous.

(c) OTRs are not always locally available (previous OTRs may be
requested from another MTF). If not utilized for three years, OTRs may be retired.

(4) Patient categories for whom the OTR is prepared.

(a) Retired service members.

(b) Family members of active duty, retired, and deceased service

members.

(c) Civil service employees, when appropriate.

(d) Any civilian receiving emergency treatment at an MTF.

(e) Foreign nationals.

c. Inpatient Treatment Record (ITR).

(1) Description. The inpatient treatment record is used at an MTF that has
authorized beds for inpatient medical or dental care. It is initiated on admission to the
MTF and completed at the end of hospitalization.

(2) Forms. DA Forms 3444-series are used as file folders for inpatient
treatment records.

(3) Characteristics unique to the ITR.

(a) The ITR pertains to one course of treatment.

(b) A patient may have more than one ITR.

MD0750 3-5
 (4) Patient categories for whom the ITR is prepared.

(a) Every bed patient (military or civilian) in a hospital, fixed health clinic,
or convalescent center.

(b) Each liveborn infant delivered in one of those MTFs described in

paragraph (1) above.

(c) Carded for Record Only (CRO) cases. Military personnel treated as
outpatients for wounds incurred in action or patients dead on arrival at the MTF.

d. U.S. Field Medical Card (FMC).

(1) Description. A medical record used by aid stations, clearing stations, and
nonfixed troop or health clinics operating overseas, on maneuvers, or attached to
commands moving between stations. Data recorded on the FMC is similar to that
recorded on the Inpatient Treatment Record Cover Sheet, i.e., the name, SSAN and
grade of the patient and a brief description of medical care given. For transfer cases,
the FMC will be attached to the patient's clothing and will remain with him until he is
returned to duty or his arrival at a hospital. If the patient dies, the FMC will remain
attached to the body until interment.

(2) Form. DD Form 1380 is the U.S. Field Medical Card. DA Form 4006
(Field Medical Record Jacket) may be used as an envelope for the FMC.

(3) Characteristics unique to the FMC.

(a) The FMC may be used for all patient categories.

(b) The use of the FMC is covered by NATO STANAG 2132 and
QSTAG 470.

(4) Situations for which the FMC is prepared.

(a) The FMC is used when any patient is treated at an aid station,
clearing station, or nonfixed troop or health clinic.

(b) The FMC is used for transfers between aid stations, clearing stations,
and nonfixed troop and health clinics.

(c) The FMC is used to record outpatient treatment in combat situations

when the health record is not readily available. It may also be used in mass casualty
situations. The original FMC is then filed in the patient's HREC or OTR.

(d) The FMC is used to prepare the Inpatient Treatment Record when a
transfer patient arrives at the hospital. The FMC then becomes part of the ITR.

MD0750 3-6
 (e) For Carded for Record Only (CRO) cases.

e. The preparation and use of these records are covered in later subcourses.

Continue with Exercises

MD0750 3-7
EXERCISES, LESSON 3

INSTRUCTIONS. The following exercises are to be answered by marking the lettered

response that best answers the question, by completing the incomplete statement, or by
writing the answer in the space provided at the end of the question.

After you have completed all the exercises, turn to "Solutions to Exercises" at the
end of the lesson and check your answers.

1. A medical record is defined as:

____________________________________________________________________.

____________________________________________________________________.

____________________________________________________________________.

2. Define Inpatient Treatment Record (ITR).

____________________________________________________________________.

____________________________________________________________________.

3. What characteristics are unique to the Outpatient Treatment Record (OTR)?

____________________________________________________________________.

____________________________________________________________________.

____________________________________________________________________.

4. Which of the following forms is used to record outpatient visits in combat

situations when the health record is not readily available?

a. DA Form 600.
b. DA Form 4254.
c. DD Form 1380.
d. DD Form 2005.

MD0750 3-8
 5. What are the six purposes of a medical record?

a. _______________________________________________________.

b. _______________________________________________________.

c. _______________________________________________________.

d. _______________________________________________________.

e. _______________________________________________________.

f. _______________________________________________________.

6. What does confidentiality mean regarding the status of medical records?

____________________________________________________________________
____________________________________________________________________.

7. The form used as a file folder for the health record (HREC) is:

____________________________________________________________________.

Check Your Answers on Next Page

MD0750 3-9
SOLUTIONS TO EXERCISES, LESSON 3

1. Any military or civilian document that gives information on the evaluations,

findings, diagnoses, and treatment of a patient. (para 3-2a)

2. A record prepared by a hospital, convalescent center, or fixed troop/health clinic

for any patient admitted for inpatient medical or dental care. (para 3-2d)

3. Not permanent, not necessarily continuous, and not always locally available.
(para 3-5b(3))

4. c. (para 3-5d(4)(c))

5. a. To provide a record of patient care and treatment.

b. To plan patient care.
c. To provide a means of communication.
d. To protect the interest of the patient and the government.
e. To provide documentation for accreditation.
f. To provide data for medical research. (para 3-4)

6. Guarding the privacy of medical information. (para 3-3b)

7. DA Forms 3444 - series. (para 3-5a(2))

End of Lesson 3

MD0750 3-10
 COMMENT SHEET

SUBCOURSE MD0750 Introduction to Medical Records and the EDITION 100

Patient Administration Division
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PRIVACY ACT STATEMENT (AUTHORITY: 10USC3012(B)

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U.S. ARMY MEDICAL DEPARTMENT CENTER AND SCHOOL Fort Sam Houston, Texas 78234-6130