2.3, 3.1

Armed forces health longitudinal application

AHLTA

Armed forces health longitudinal application (AHLTA)

used primarily for outpatient care

beneficiary

a person eligible to receive care in an MTF

Composite health care system

CHCS

Composite health care system (CHCS)

mainframe based system to electronically perform patient appointment processes and scheduling, order laboratory tests, and prescribe medications

Defense enrollment eligibility reporting system

DEERS

Defense enrollment eligibility reporting system (DEERS)

authoritative data repository used to verify an individuals identity and affiliation with the DoD

Dental treatment facility (DTF)

fixed facility of the DoD that is outside of a deployed environment and used primarily for dental care and services

disposition

the method in which a health record is managed after its period of active use

Essentris

the military’s inpatient electronic health record

Health artifact and image management solution

HAIMS

Health artifact and image management solution (HAIMS)

used by the DoD to store digitized health record portable documentation. available to VA for claims resolution purposes

medical readiness reporting system

MRRS

medical readiness reporting system (MRRS)

web-based tool designed to record and track individual medical readiness (IMR)

Military medical treatment facility (MTF)

outside of a deployed environment and used primarily for health care

MHS GENESIS

DoD’s most recent EHR system for both outpatient and inpatient health care

active duty

AD

active duty service member

ADSM

family member prefix

FMP

non-service treatment record

NSTR

occupational health civilian employee treatment record

OHTR

service treatment record

STR

Unit identification code

UIC

service treatment record (STR), non-service treatment record (NSTR), occupational health civilian employee treatment record (OHTR), and inpatient record

principle component records of the DoD health record include:

STR

health records of a service member

NSTR

health records for a spouse

OHTR

health records for civilian contracters

inpatient record

health records of patients receiving inpatient treatment

dental records

information reflecting dental treatment and corresponding X-rays or digital films provided to individuals

mental health records

included in the DoD health record as part of the STR, NSTR, and OHTR

Secondary records

known as back up, duplicative, or shadow files, are unauthorized for use in the MHS to prevent serious patient safely issues

72 hours

all loose, paper clinical documentation that should be part of the DoD health record but cannot be entered in EHR systems will be uploaded into HAIMS or MHS GENESIS within _______

patients full name, date of birth, last for digits of SSN/ DoD ID number, and name of the MTF maintaining health record

all documents in the health record will contain what minimum patient identification information?

single line incorrect information, note it as error with date and initials

how do you correctly fix mistakes on paper records?

20

FMP number for active duty member:

black ink

on health record what are allergies marked with?

01-19

FMP number for children of sponsor:

30-39

FMP number for spouse of sponsor:

60-69

FMP number for other authorized dependents:

99

FMP number for foreign nationals, etc.:

parts 2 and 3

are located on the middle flap of the folder, with fasteners at the top

part 2 front of center page

contains preprinted DD 2005, privacy act statement. patients must sign and date the form in black ink

retired year tape block

In the hard copy record place ½ inch piece of cellophane tape in the box

outpatient active duty

in the hard copy record what does red tape mean in the record category tape block?

outpatient non-active duty

in the hard copy record what does black tape mean in the record category tape block?

inpatient

in the hard copy record what does green tape mean in the record category tape block?

DD form 2766

adult preventive and chronic care flowsheet

DD Form 2215

reference audiogram

DD Form 2216

hearing conservation data

NAVMED 6150/7

charge-out form (pink card)

SF 600

Chronological record of medical care

DD form 2005

privacy act statement - health care records

SF 511

vital signs record

charge-out form (pink card)

serves as a permanent record of receipt and disposition of the health record

March 31st

all facilities maintaining DoD health records will conduct an annual inventory of STRs no later than ________

Service treatment record processing operations reporting tracking solution

SPORTS

prefix

the word part attached to the beginning of the term

Dyspnea

bad, painful, difficult, abnormal

Hypotension

below, less than normal, under

Tachypnea

fast

root

provides the basic meaning of the term

Cardiac

relating to the heart

Arthritis

painful inflammation in the joint

Hypoglycemia

deficiency of glucose in the bloodstream

suffix

ending of the word structure

hematology

study of

dermatitis

inflammation of

Gastric/Cardiac/Rectal

related to/pertaining to

dyspnea

breath, breathing

acute

patient with a sudden flare up or potentially severe condition who needs immidiate care

cerebrovascular accident (CVA)

commonly called a stroke. occurs when the brain is deprived of blood and oxygen by either a blockage or the rupture of a blood vessel

cyanosis

condition resulting bluish skin, stems from lack of oxygen in the blood

hypertension

abnormally high blood pressure

hypotension

abnormally low blood pressure

myocardial infarction

when an arterial blockage or slow blood flow deprives the heart of blood. known as a heart attack

tension pneumothorax

a collapsed lung that occurs when air leaks into the space between the lungs and the chest wall

PO

taken by mouth or orally

PRN

take as needed

PR

rectally

bounding

a strong throbbing pulse due to a forceful heartbeat

ilium

bone in the pelvis

ileum

portion of the small intestine

abduction

to move away from the midline of your body

adduction

to move toward the midline of the body

dysphasia

difficulty speaking or understanding words

dysphagia

difficulty swallowing

AO x 3

alert and oriented to person, place, time

AVPU

refers to the level of consciousness (alert, verbal, pain, unresponsive)

EKG/ECG

electrocardiogram. records the electrical signals in the heart

HR

heart rate, expressed as beats per minute

SPO2

oxygen saturation (pule oximetry)

Pulse

P

Respiratory rate

RR

Temperature

Temp/T

blood, urine, defecation

BUD

Deformities, contusions, abrasions, puncture, burns, tenderness, lacerations, swelling

DCAPBTLS

gastroesophageal reflux disease

GERD

mechanism of injury

MOI

onset, provocation, relief, severity, time

OPQRST

return of spontaneous circulation

ROSC