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.
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
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.