Record Description
Outpatient/Health Treatment Records
Health/Outpatient Treatment Records (HRECs/OTRs) are maintained in three separate file locations. The main office is located in the hospital, Building 7777, Room 3-229. Health Records (HRECs) of active duty assigned to WBAMC, family members, retired personnel, and VA patients treated at WBAMC are maintained in this file room. The Soldier and Family Medical Clinic (SFMC), Building 2496, at Ft. Bliss maintains HRECs/OTRs of active duty and family members enrolled in the Family Practice Clinic. Another clinic is located at McAfee Health Clinic, White Sands Missile Range, New Mexico, maintains records of active duty, family members, and retired personnel. Patients visiting clinics at WBAMC and the SFMC may expect that their records will be provided to the appropriate clinic prior to their appointment. Patients with walk-in appointments or who make next-day or same-day appointments may also expect that their records will be available to the appropriate clinic. For the patient’s convenience, the Outpatient/Health Treatment Record Sections maintains a “closed” record system meaning that patients no longer required to pick up their records prior to their appointment. This arrangement not only allows the patient more time to arrive at their appointment, but it also provides for more accountability of records. Patients with records maintained at other military health clinics must hand-carry their medical records to clinics. When active duty military patients and family members are PCSing, they will no longer be allowed to hand-carry their original HREC/OTRs to the receiving health treatment facility. At least one month prior to PCSing, military personnel should present a copy of their orders to the appropriate Health/Outpatient Treatment Record Section so that arrangements can be made for all laboratory and radiographic reports to be printed and so that copies of their records can be made in order for them to be available in route and to present the records to the receiving health treatment facility. One week prior to out processing, the Health/Outpatient Record Section should be visited to pick up the copy of the HREC/OTR. Any questions should be directed to the Supervisor, Health/Outpatient Treatment Record Section at 915-569-2198.
Information about Patient Medical Records
The original record of your treatment in a military medical treatment facility is the property of the U.S. Government. Each patient is entitled to a copy of his/her medical record; however, the original record is government property and must remain in the custody of Patient Administration Division at a government facility, and there are penalties for not returning records to the appropriate office. Please refer to the information under the Correspondence Section for instructions regarding requests for medical records. William Beaumont Army Medical Center maintains the following types of medical records.
Inpatient Treatment Record(ITR)
Records of patients who were admitted in the hospital over 24 hours. Original ITRs may be used for subsequent patient care, reimbursement, research, and use by regulatory agencies. These records never leave the hospital unless required by court order. If there is no subsequent treatment, these records will be retired after five (5) years. If a patient is subsequently admitted to the hospital within the 5-year time frame, the records will be updated and maintained in the hospital until such time as there is no re-occurring treatment within the five year period. ITRs are retired to the National Records Depository in St. Louis, Missouri.
Outpatient Treatment Record (OTR)
This record is maintained on retired military personnel, family members, dual VA beneficiaries, and civilian emergency patients. This record contains documentation of visits to clinics for treatment, immunizations, consultations, laboratory and radiographic reports. OTRs are provided to the clinics for appointments and then returned to the Outpatient Treatment Record Section, Room 3-229, the Soldier and Family Medical Clinic, or the McAfee Health Clinic at White Sands Missile Range. An OTR may be taken from the MEDCEN by a patient only when needed by a TRICARE Primary Care Physician. If there is no-reoccurring treatment within a three (3) year period, OTRs are retired to the National Records Deposition in St. Louis, Missouri.
Health Treatment Records (HREC)
This record is maintained on active duty personnel. This record contains documentation of visits to clinics for treatment, immunizations, consultations, laboratory and radiographic reports. HRECs are provided to the clinics for appointments and then returned to the Outpatient Treatment Record Section, Room 3-229. HRECs are provided to the clinics for appointments and then returned to the Outpatient Treatment Record Section, Room 3-229, the Soldier and Family Medical Clinic, or the McAfee Health Clinic at White Sands Missile Range. Copies of HRECs will be provided to the active duty member and his/her family members upon PCSing. ETSing personnel will be provided a copy of their records if requested. Upon retirement of the active members, HRECs are sent to the Veterans Regional Office.
Ambulatory Procedure Visit (APV)
Also known as Same-Day Surgery, or Enhanced Ambulatory Record (EAR). This record is generated when a patient is scheduled for a same day procedure and comes to the Ambulatory Procedure Unit, or a clinic, and is then released on the same day; the stay cannot exceed 23 hours and 59 minutes. If complications require an extended stay, the patient is admitted and the record will be incorporated into and inpatient treatment record. The same standard for maintenance and retirement of an ITR apply for an ambulatory procedure visit record.
Consultation Files
A Consultation File contains original patient information, which is not kept in the original outpatient treatment record or health record. For example, documentation of psychological treatment, social work, or patients undergoing drug and alcohol treatment will not be placed in theHEEC/ OTR. A patient encounter form will be generated with the patient identification and date of the encounter; however, a cross-reference will be made to the specific consultation file.
OB Record/Prenatal Record
This record contains documentation of prenatal obstetrical care received at WBAMC. If the patient delivers at WBAMC, All documentation belonging to pregnancy episode will be incorporated into the ITR. If patient does not deliver here or pregnancy is terminated, documentation is filed in the outpatient treatment record. If the patient delivers at WBAMC, the record will be maintained as an inpatient treatment record and the same maintenance and retirement procedures apply. If the patient does not deliver at WBAMC or the pregnancy is terminated, then the same procedures as for the maintenance and retirement of an outpatient treatment record apply.
Convenience File
Duplicate files maintained by some clinics for physician reference only. They must contain no original written medical documentation; however, duplicate electronic documents may be maintained in the convenience file. This is not an official file.