ARMY AR 40-66 [ Revised ]

Applicability.

This regulation applies to the Active Army, the Army National Guard/Army National Guard of the United States, and the U.S. Army Reserve unless otherwise stated. Also it applies to other members of the uniformed services of Allied nations who receive medical treatment or evaluation in an Army military treatment facility. This publication is applicable during mobilization.

Purpose

a. This regulation sets policies and procedures for the preparation, disposition, and use of Army electronic and paper medical records and other health care documentation discussed in the following chapters.

b. The purpose of a medical record is to provide a complete medical and dental history for patient care, medicolegal support (for example, reimbursement and tort claims), research, and education. A medical record also provides a means of communication, where necessary, to fulfill other Army functions (for example, identification of remains).

c. The following types of health–care records will be used to document medical and dental care. All care provided to beneficiaries as hospital inpatients will be recorded in an inpatient treatment record (ITR). Outpatient care on a military member will be recorded in either the member’s treatment record or dental record. Combined, the treatment record and dental record are considered a health record (HREC). Care provided to nonmilitary beneficiaries will be documented in an outpatient treatment record (OTR) that includes a separate dental record. Both military and nonmilitary personnel enrolled in the Army Substance Abuse Program (ASAP) will have an ASAP outpatient medical record (ASAP–OMR). Occupational and nonoccupational outpatient care provided to a civilian employee will be recorded in a civilian employee medical record (CEMR).

d. The ability to retrieve the documentation of care provided to patients is paramount. The original documentation of outpatient care will be maintained at the medical treatment facility (MTF) where it was created. These documents will be maintained separately from health records (HREC), outpatient treatment records (OTR), and civilian employee medical records (CEMR). The MTFs which currently have access to electronic records documentation generating and storage systems may continue their use until the Composite Health Care System II (CHCS II) is implemented at that MTF. The MTFs that do not have access to electronic information systems must implement a paper medical document storage and retrieval system (see DODI 6040.43).