INITIATING AND FILING MEDICAL RECORDS
Section I. INTRODUCTION
A record of medical care is an essential part of any health care system. Civilian
physicians prepare records of the medical care they provide to outpatients whom they treat
in their office or clinic. These records belong to the physician and the medical facilities, not
to the patients. A similar procedure is followed by the Army. A record of outpatient care is
prepared, but Army physicians are not in private practice, so all medical records they
prepare belong to the Army. Because many different personnel are involved in the
preparation of these medical records (physicians, nurses, dentists, corpsmen, patient
administration specialists, and others), the Army has specific written rules for preparing
them. These rules are covered in AR 40-66.
The Army uses two types of medical records to record outpatient care; the Health
Record and the Outpatient Treatment Record. The status of the patient or patient category
determines which type will be used. The individual types of outpatient medical records are
discussed in other lessons within this subcourse. There are also inpatient medical
records. The Inpatient Treatment Record is discussed in Subcourse MD0753.
CUSTODIAN OF ME DICAL RECORDS
The medical treatment facility (MTF) commander is the custodian of the medical
records of patients given care in facilities under his jurisdiction. He in turn delegates this
responsibility to the Chief, Patient Administration Division.
The Chief, Patient
Administration Division, with the assistance of patient administration personnel assigned
to his office, is responsible for the maintenance of the outpatient medical records. He
reviews the records to assure compliance with Army Regulations and accreditation
standards of the Joint Commission on Accreditation of Hospital Organizations (JCAHO).