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).