Medical Record Administration and Healthcare Documentation

215 Pages·2010·2.39 MB·English

Army Regulation 40–66
Medical Services
Medical
Record
Administration
and Healthcare
Documentation
Rapid Action Revision (RAR) Issue Date: 4 January 2010
Headquarters
Department of the Army
Washington, DC
17 June 2008
UNCLASSIFIED
SUMMARY of CHANGE
AR 40–66
Medical Record Administration and Healthcare Documentation
This rapid action revision, dated 4 January 2010--
o Requires the appointment of a Health Insurance Portability and Accountability
Act privacy officer (para 1-4a(6)).
o Involves the unit surgeon in the communication of a Soldier’s protected
health information to a unit commander (para 1-4a(12)).
o Promotes the perception of the medical record as patient-centric rather than
provider-centric (para 1-4a(13)).
o Outlines the duty of a division, brigade, or battalion surgeon in supporting
unit commanders’ decisionmaking (para 1-4e(5)).
o Provides for the military treatment facility commander and privacy officer to
determine role-based access to protected health information (para 2-2e).
o Requires that Health Insurance Portability and Accountability Act be
accomplished within 30 days of personnel assignment to a military treatment
facility and annually during their birth month thereafter (para 2-2e).
o Describes the use of protected health information in a military treatment
facility directory (para 2-3c).
o Allows disclosure of protected health information to a Family member, other
relative, or a close personal friend of the individual (para 2-3d).
o Permits the disclosure of protected health information to a public or private
entity authorized by law or by its charter to assist in disaster relief
efforts (para 2-3e).
o Identifies regulatory programs that do not require the Soldier’s
authorization for protected health information disclosure (para 2-4a).
o Provides for the proactive notification of a Soldier’s commander in certain
instances (para 2-4a(2)).
o Describes the processes for notifying a commander of a Soldier’s protected
health information (para 2-4a(3)(a) through 2-4a(3)(d)).
o Implements DA Form 3822 (Report of Mental Status Evaluation) (para 2-
4a(3)(c)).
o Provides new guidance for sharing a patient’s protected health information
with the Department of Veterans Affairs (para 2-4b).
o Delineates specific accounting of protected health information disclosures
made without patient authorization (para 2-4e).
o Permits a patient to receive communications of protected health information
by alternate means or at alternate locations (para 2-5o).
o Provides for incidental disclosures of protected health information (para 2-
5p).
o Requires that entries in all electronic and paper records be made in all
inpatient, outpatient, service treatment, dental, Army Substance Abuse
Program, and occupational health records by the healthcare provider who
observes, treats, or cares for the patient at the time of observation,
treatment, or care (paras 3-4a, 8-9).
o Provides new Army Substance Abuse Program documentation policy (para 5-22a,
5-22d, 5-22e).
o Requires that copies of service treatment records/outpatient treatment
records belonging to wounded warriors departing the Army and Family members
of wounded warriors be transferred to their civilian provider (para 5-30c and
6-6d).
o Provides updated guidance on behavioral health records (para 6-7h).
o Implements and integrates DA Form 7656 (Tactical Combat Casualty Care (TCCC)
Card) into healthcare documentation process (chap 15).
o Provides the requirements for use, preparation, and disposition of DA Form
7656 (Tactical Combat Casualty Care (TCCC) Card) by first responders, when
providing point-of-injury care to Soldiers injured in the theaters of
operation (chap 15).
o Adds a new key management control test question (para C-4p).
o Makes additional rapid action revision changes (chaps 2,3,5,6,8, and 9).

Headquarters *Army Regulation 40–66
Department of the Army
Washington, DC
17 June 2008 Effective 17 July 2008
Medical Services
Medical Record Administration and Healthcare Documentation
States, and the U.S. Army Reserve, unless Army management control process.
otherwise stated. Also, it applies to other This regulation contains management con-
members of the uniformed services of Al- trol provisions and identifies key manage-
l i e d n a t i o n s w h o r e c e i v e m e d i c a l t r e a t - ment controls that must be evaluated. (See
ment or evaluation in an Army military appendix C.)
t r e a t m e n t f a c i l i t y . D u r i n g m o b i l i z a t i o n ,
the proponent may modify chapters and S u p p l e m e n t a t i o n . S u p p l e m e n t a t i o n o f
policies contained in this regulation. this regulation and establishment of com-
mand and local forms are prohibited with-
Proponent and exception authority.
o u t p r i o r a p p r o v a l f r o m T h e S u r g e o n
The proponent of this regulation is The
General (DASG-HS-AP), 5109 Leesburg
Surgeon General. The proponent has the
Pike, Falls Church, VA 22041–3258.
authority to approve exceptions or waivers
to this regulation that are consistent with
Suggested improvements. Users are
controlling law and regulations. The pro-
invited to send comments and suggested
ponent may delegate this approval author-
improvements on DA Form 2028 (Recom-
ity, in writing, to a division chief within
History. This publication is a rapid action m e n d e d C h a n g e s t o P u b l i c a t i o n s a n d
the proponent agency or its direct report-
revision (RAR). This RAR is effective 4 Blank Forms) directly to Office of The
ing unit or field operating agency, in the
F e b r u a r y 2 0 1 0 . T h e p o r t i o n s a f f e c t e d b y S u r g e o n G e n e r a l ( D A S G - H S - A P ) , 5 1 0 9
grade of colonel or the civilian equivalent.
t h i s R A R a r e l i s t e d i n t h e s u m m a r y o f L e e s b u r g P i k e , F a l l s C h u r c h , V A
Activities may request a waiver to this
change. 22041–3258.
regulation by providing justification that
S u m m a r y . T h i s r e g u l a t i o n p r e s c r i b e s includes a full analysis of the expected
Distribution. This publication is availa-
policies for preparing and using medical benefits and must include formal review
ble in electronic media only and is in-
r e p o r t s a n d r e c o r d s i n a c c o r d a n c e w i t h by the activity’s senior legal officer. All
tended for command levels A, B, C, D,
North Atlantic Treaty Organization Stand- waiver requests will be endorsed by the
and E for the Active Army, the Army
ardization Agreements 2348 ED.3(1) and commander or senior leader of the requ-
National Guard/Army National Guard of
2 1 3 2 E D . 2 a n d A m e r i c a n – B r i t i s h – e s t i n g a c t i v i t y a n d f o r w a r d e d t h r o u g h
Canadian–Australian Quadripartite Stand- t h e i r h i g h e r h e a d q u a r t e r s t o t h e p o l i c y t h e U n i t e d S t a t e s , a n d t h e U . S . A r m y
ardization Agreement 470 ED.1. proponent. Refer to AR 25–30 for specific Reserve.
Applicability. This regulation applies to guidance.
t h e A c t i v e A r m y , t h e A r m y N a t i o n a l
Guard/Army National Guard of the United
Contents (Listed by paragraph and page number)
Chapter 1
Introduction, page 1
Purpose (cid:129) 1–1, page 1
References (cid:129) 1–2, page 1
Explanation of abbreviations and terms (cid:129) 1–3, page 1
Responsibilities (cid:129) 1–4, page 1
Background (cid:129) 1–5, page 3
Record ownership (cid:129) 1–6, page 3
International standardization agreements (cid:129) 1–7, page 4
*This regulation supersedes AR 40–66, dated 21 June 2006. This edition publishes a rapid action revision of AR 40–66.
AR 40–66 (cid:129) 17 June 2008/RAR 4 January 2010 i
UNCLASSIFIED
Contents—Continued
Chapter 2
Confidentiality of PHI, page 4
General (cid:129) 2–1, page 4
Policies governing protected health information (cid:129) 2–2, page 4
Release of information when the patient consents to disclosure (cid:129) 2–3, page 5
Disclosure without consent of the patient (cid:129) 2–4, page 7
Processing requests for protected health information, restrictions, and revocations (cid:129) 2–5, page 9
Medical records of teenage Family members (cid:129) 2–6, page 11
Disclosure of medical records containing classified defense information (cid:129) 2–7, page 12
Research using military medical records (cid:129) 2–8, page 13
Chapter 3
Preparation of Medical Records, page 13
Section I
Forms and Documents, page 13
Authorized forms and documents (cid:129) 3–1, page 13
Filing electronic/computerized forms (cid:129) 3–2, page 14
Guidelines for local forms and overprints (cid:129) 3–3, page 14
Section II
Medical Record Entries, page 15
General (cid:129) 3–4, page 15
Patient identification (cid:129) 3–5, page 16
Facility identification (cid:129) 3–6, page 17
Destruction of unidentifiable medical documents (cid:129) 3–7, page 18
Section III
Recording Diagnoses and Procedures, page 18
Nomenclature used in recording diagnoses (cid:129) 3–8, page 18
Special instructions for certain diseases (cid:129) 3–9, page 18
Special instructions for certain diagnoses (cid:129) 3–10, page 18
Recording psychiatric conditions (cid:129) 3–11, page 19
Recording injuries (cid:129) 3–12, page 19
Recording deaths (cid:129) 3–13, page 20
Recording cases observed without treatment, undiagnosed cases, and causes of separation (cid:129) 3–14, page 20
Recording surgical, diagnostic, and therapeutic procedures (cid:129) 3–15, page 20
Recording therapeutic abortions (cid:129) 3–16, page 20
Recording use of restraints/seclusion (cid:129) 3–17, page 21
Recording videotaped documentation of episodes of medical care (cid:129) 3–18, page 21
Section IV
Records for Carded–for–Record–Only Cases and Absent–Sick Status, page 21
Carded–for–record–only cases (cid:129) 3–19, page 21
Absent–sick status (cid:129) 3–20, page 21
Section V
Detainee Records, page 23
Documentation of detainee care (cid:129) 3–21, page 23
Maintenance and transfer of records (cid:129) 3–22, page 23
Release of information (cid:129) 3–23, page 23
Chapter 4
Filing and Requesting Medical Records, page 23
Filing by Social Security number and Family member prefix (cid:129) 4–1, page 23
Terminal digit filing system (cid:129) 4–2, page 24
ii AR 40–66 (cid:129) 17 June 2008
Contents—Continued
Use of DA Form 3443–series, DA Form 3444–series, and DA Form 8005–series folders (cid:129) 4–3, page 24
Preparation of DA Form 3444–series and DA Form 8005–series folders (cid:129) 4–4, page 25
Preparation of DA Form 3443–series folders (cid:129) 4–5, page 26
Record chargeout system (cid:129) 4–6, page 27
Record requests (cid:129) 4–7, page 27
Chapter 5
Service Treatment Records, page 30
Section I
General, page 30
Purpose of the service treatment record (cid:129) 5–1, page 30
Use of the service treatment record (cid:129) 5–2, page 31
For whom prepared and maintained (cid:129) 5–3, page 32
Forms and documents of service treatment records (cid:129) 5–4, page 32
DA Form 5007A and DA Form 5007B (cid:129) 5–5, page 32
DA Form 5008 (cid:129) 5–6, page 32
DA Form 5181 (cid:129) 5–7, page 32
DA Form 5569 (cid:129) 5–8, page 32
DA Form 5570 (cid:129) 5–9, page 32
DD Form 2882 (cid:129) 5–10, page 32
DD Form 1380 (cid:129) 5–11, page 33
DD Form 2482 (cid:129) 5–12, page 33
DD Form 2766 and DD Form 2766C (cid:129) 5–13, page 33
DD Form 2813 (cid:129) 5–14, page 33
SF 512 (cid:129) 5–15, page 34
SF 558 (cid:129) 5–16, page 34
SF 559 (cid:129) 5–17, page 34
SF 600 (cid:129) 5–18, page 34
Immunization documentation (DD Form 2766, SF 601, and CDC Form 731) (cid:129) 5–19, page 36
SF 603 and SF 603A (cid:129) 5–20, page 37
Other forms filed in the service treatment record (cid:129) 5–21, page 38
Service treatment records with behavioral health documentation (cid:129) 5–22, page 40
Access to service treatment records (cid:129) 5–23, page 40
Cross–servicing of service treatment records (cid:129) 5–24, page 41
Section II
Initiating, Keeping, and Disposing of Service Treatment Records, page 41
Initiating service treatment records (cid:129) 5–25, page 41
Transferring service treatment records (cid:129) 5–26, page 42
Handcarrying medical records (cid:129) 5–27, page 43
Establishing “temporary” and “new” service treatment records (cid:129) 5–28, page 44
Filing service treatment records (cid:129) 5–29, page 44
Disposing of service treatment records (cid:129) 5–30, page 46
Section III
Special Considerations for Personnel Reliability Program Service Treatment Records and Civilian Employee Medical
Records, page 46
Screening Personnel Reliability Program records (cid:129) 5–31, page 46
Maintaining Personnel Reliability Program records (cid:129) 5–32, page 46
Section IV
Maintenance of Service Treatment Records and Civilian Employee Medical Records Upon Mobilization, page 47
Paper service treatment records of deployed military members and deployed civilians (cid:129) 5–33, page 47
Preparation of service treatment record forms (cid:129) 5–34, page 47
AR 40–66 (cid:129) 17 June 2008 iii
Contents—Continued
Use of field files/DD Form 2766 (cid:129) 5–35, page 48
Health assessments after deployment (cid:129) 5–36, page 48
Operation after hostilities cease (cid:129) 5–37, page 49
Chapter 6
Outpatient Treatment Records, page 66
Section I
General, page 66
For whom prepared (cid:129) 6–1, page 66
Outpatient treatment record forms and documents: Guidelines for paper record preparation and use (cid:129) 6–2, page 66
Section II
Initiating, Keeping, and Disposing of Outpatient Treatment Records, page 67
Initiating and keeping outpatient treatment records (cid:129) 6–3, page 67
Transferring outpatient treatment records (cid:129) 6–4, page 67
Requests other than DD Form 2138 (cid:129) 6–5, page 68
Disposition (cid:129) 6–6, page 68
Section III
Preparation and Use of Outpatient Treatment Records, page 69
Preparation (cid:129) 6–7, page 69
Use (cid:129) 6–8, page 70
Chapter 7
Occupational Health Program Civilian Employee Medical Record, page 83
Section I
General, page 83
Compliance (cid:129) 7–1, page 83
Definition and purpose of the civilian employee medical record (cid:129) 7–2, page 83
For whom prepared (cid:129) 7–3, page 83
Civilian employee medical records folder and forms (cid:129) 7–4, page 83
Section II
Maintaining, Transferring, and Disposing of Civilian Employee Medical Records and Retention of Job–Related
X–Ray Films, page 84
Custody and maintenance of civilian employee medical records (cid:129) 7–5, page 84
Medical record entries (cid:129) 7–6, page 84
Recording occupational injuries and illnesses (cid:129) 7–7, page 84
Cross–coding of medical records (cid:129) 7–8, page 84
Transferring and retiring civilian employee medical records (cid:129) 7–9, page 85
Retention of job–related x–ray films (cid:129) 7–10, page 85
Section III
Confidentiality of PHI, Access to Civilian Employee Medical Records, and Performance Improvement, page 85
Protection of confidentiality and disclosure procedures (cid:129) 7–11, page 85
Civilian employee medical record review (cid:129) 7–12, page 85
Chapter 8
Army Substance Abuse Program Outpatient Medical Record, page 90
Section I
General, page 90
For whom prepared (cid:129) 8–1, page 90
Access (cid:129) 8–2, page 90
iv AR 40–66 (cid:129) 17 June 2008
Contents—Continued
Disclosure of information (cid:129) 8–3, page 90
Forms and documents (cid:129) 8–4, page 91
Section II
Initiating, Maintaining, and Disposing of Army Substance Abuse Program Outpatient Medical Records, page 91
Initiating and maintaining (cid:129) 8–5, page 91
Transferring (cid:129) 8–6, page 91
Requests other than DD Form 2138 (cid:129) 8–7, page 91
Disposition (cid:129) 8–8, page 91
Section III
Preparation and Use of Army Substance Abuse Program Outpatient Medical Records, page 91
Preparation (cid:129) 8–9, page 91
Use (cid:129) 8–10, page 92
Chapter 9
Inpatient Treatment Records, page 94
Section I
General, page 94
For whom prepared (cid:129) 9–1, page 94
Inpatient forms and documents (cid:129) 9–2, page 95
Fetal monitoring strips (cid:129) 9–3, page 95
Section II
Initiating, Keeping, and Disposing of Inpatient Treatment Records, page 96
General (cid:129) 9–4, page 96
Records for Ambulatory Procedure Visit patients (cid:129) 9–5, page 96
NATO STANAG 2348 ED.3(1) requirements (cid:129) 9–6, page 96
Inpatient treatment records of AWOL patients (cid:129) 9–7, page 96
Five–year inpatient treatment record maintenance (cid:129) 9–8, page 96
Access and audit trail (cid:129) 9–9, page 96
Disposition of inpatient treatment records (cid:129) 9–10, page 97
Section III
Preparation and Use of Inpatient Treatment Records, page 97
Inpatient treatment records content (cid:129) 9–11, page 97
Medical reports (cid:129) 9–12, page 98
Nursing process documentation (cid:129) 9–13, page 100
Countersignatures (cid:129) 9–14, page 102
Section IV
DA Form 3647, page 103
General purpose (cid:129) 9–15, page 103
Use (cid:129) 9–16, page 103
Initiation and disposition (cid:129) 9–17, page 103
Preparation (cid:129) 9–18, page 103
Corrections and corrected copies (cid:129) 9–19, page 103
Section V
Preparation and Use of Other Inpatient Treatment Record Forms, page 104
DD Form 2569 (cid:129) 9–20, page 104
DD Form 2770 (cid:129) 9–21, page 104
DA Form 4359 (cid:129) 9–22, page 104
DD Form 792 (cid:129) 9–23, page 104
DA Form 3950 (cid:129) 9–24, page 104
AR 40–66 (cid:129) 17 June 2008 v
Contents—Continued
Laboratory test requisition and reporting forms (cid:129) 9–25, page 104
DA Form 4256 (cid:129) 9–26, page 105
DA Form 4677 (cid:129) 9–27, page 106
DA Form 4678 (cid:129) 9–28, page 107
DA Form 4107 (cid:129) 9–29, page 108
DA Form 7001 (cid:129) 9–30, page 109
DD Form 1924 (cid:129) 9–31, page 110
DA Form 4108 (cid:129) 9–32, page 110
DA Form 5179 (cid:129) 9–33, page 111
DA Form 5179–1 (cid:129) 9–34, page 111
SF 511 (cid:129) 9–35, page 112
SF 519–B (cid:129) 9–36, page 112
DA Form 5009 (cid:129) 9–37, page 113
Chapter 10
Extended Ambulatory Records, page 124
Section I
General, page 124
Purpose of the extended ambulatory record (cid:129) 10–1, page 124
For whom prepared (cid:129) 10–2, page 124
Extended ambulatory record forms and documents (cid:129) 10–3, page 124
Section II
Initiating, Keeping, and Disposing of Extended Ambulatory Records, page 124
Initiating extended ambulatory records (cid:129) 10–4, page 124
Five–year/one–year extended ambulatory record maintenance (cid:129) 10–5, page 124
Disposition of extended ambulatory records (cid:129) 10–6, page 125
Section III
Preparation and Use of Extended Ambulatory Records, page 125
Preparation of extended ambulatory records (cid:129) 10–7, page 125
Use of extended ambulatory records (cid:129) 10–8, page 125
Chapter 11
DD Form 1380, page 129
Use (cid:129) 11–1, page 129
Preparation (cid:129) 11–2, page 129
Supplemental DD Form 1380 (cid:129) 11–3, page 130
Disposition (cid:129) 11–4, page 130
DA Form 4006 (cid:129) 11–5, page 130
Chapter 12
Role of the Medical Department Activity or U.S. Army Medical Center Patient Administration Division in
the Improving Organizational Performance Process, page 132
General (cid:129) 12–1, page 132
Internal performance improvement process for medical record services (cid:129) 12–2, page 132
Patient care assessment (cid:129) 12–3, page 132
Patient Administration Division role in handling medical records in the Risk Management Program (cid:129) 12–4, page 133
Chapter 13
DD Form 689, page 134
Purpose and use (cid:129) 13–1, page 134
Issuing authority (cid:129) 13–2, page 134
Procedures (cid:129) 13–3, page 134
Service treatment record entry (cid:129) 13–4, page 136
vi AR 40–66 (cid:129) 17 June 2008