2-18. USE OF HREC IN OUTPATIENT MEDICAL CARE
a. Each time a person seeks care or is treated, the Health Record is removed
from the file and used by the health care provider. The findings and treatment are
recorded on the proper forms.
b. When an MTF refers a patient elsewhere for outpatient ca re, the HREC may
be sent also. The referring or consulting practitioner will decide. If it is sent, the
consulting practitioner will comment in the record on his or her findings and treatment
on SF 513 or any other medical forms he or she deems proper, including SF 600.
These consultation and treatment records are filed in the person's Health Record.
c. When a person reports for outpatient treatment to an MTF that does not keep
his or her Health Record, the AMEDD officer will send the appropriate records to the
person's HREC custodian. Paragraph 1-3d(2) describes the procedure used.
2-19. USE OF HREC IN INPATIENT CARE
a. When a person is admitted for treatment, the Health Record is normally sent
to the MTF. When an MTF receives a HREC (or part of it), the patient administrator
becomes the custodian. He will ensure it is accessible to AMEDD personnel. When
received, the HREC is sent to the patient's ward. it is kept there during his stay for use
by the attending physician and other medical personnel involved in his case. The
patient administrator is responsible for ensuring that a copy of each of the forms
required for the HREC are prepared by the MTF and are put into the Health Record. He
will also ensure that the entries needed for inpatients on the SF 600 are made.
b. When a patient is released from the MTF , the patient administrator forwards
the HREC as follows:
(1) For attached patients returned to duty. The HREC is sent to the records
custodian of the MTF that provides the person with primary outpatient care. If the MTF
is not known, the HREC is sent to the MEDDAC or MEDCEN commander of the
person's assigned installation.
(2) For assigned patients returned to duty. The HREC is sent to the military
personnel officer of the person's assigned unit. If the person is locally reassigned, the
HREC is sent to the custodian as in paragraph (1) above.
(3) Patients transferred to another MTF. The HREC is sent with the inpatient
record to the other MTF.
(4) For deceased patients. The HREC is sent to the officer holding the
patient's personnel records. That officer will dispose of the records as discussed in