MEDICAL RECORDS AND THEIR USES
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.
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 treatme nt
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.