Medical Records of Previously Active Duty Individuals (In-Patient Hospital Data)

Medical Records of Previously Active Duty Individuals (In-Patient Hospital Data)

Accessing Clinical Records for Veterans: A Comprehensive Approach

Veterans' clinical records, spanning various branches of the military, are maintained and coordinated through a complex system involving both electronic and paper records. This system ensures the continuity of care for veterans, regardless of where they received treatment.

Requesting and Accessing Records

Veterans or their authorized representatives can request copies of military medical or dental records through the National Archives in St. Louis, which holds official military personnel records, including Service Treatment Records. For VA medical records, requests can be submitted electronically via the "Blue Button" system, providing access to individual electronic health records (EHR). Freedom of Information Act (FOIA) requests can also be made to the VA for medical and related personnel records.

Electronic Health Records (EHR) System

The Military Health System uses MHS GENESIS, a centralized EHR system across Military Treatment Facilities (MTFs), which maintains electronic records that transfer when a service member moves between installations. The Veterans Health Administration (VHA) manages electronic and paper health information at VA facilities. Health Information Management (HIM) departments scan paper documents and import electronic records to maintain comprehensive EHRs.

Community Care and Records Import

When veterans receive care in the community, outside VA facilities, community providers are contractually required to return medical records to the VA within 30 days of an appointment. A system called the "Consult Toolbox" documents and tracks the medical record retrieval process to streamline access by VA staff.

Storage and Maintenance Practices

Records are stored both as paper documents and electronically on magnetic media and cloud-based systems to ensure backup and security. Records related to veterans’ care are maintained in VA medical centers, data processing centers, and Veterans Integrated Service Networks (VISNs). Backup data is stored in web-based cloud storage systems with administrative, technical, and physical safeguards compliant with VA security policies.

Retrieval Methods

Records can be retrieved by personal identifiers such as name or Social Security Number (SSN). Provider-related records require provider or institution identifiers. Some specific records, such as those at the Automated Records Center (ARC), use SSN for retrieval.

Special Considerations

Clinical Record Libraries in military hospitals, such as Air Force hospitals from 1951 and Army hospitals from 1957, may have records that were not filed in the OMPF and were not affected by the 1973 Fire. Teaching hospitals that maintain Clinical Record Libraries may retain records up to 5 years before retirement. Clinical (hospital inpatient) records are compiled when active duty members are hospitalized while in the service.

The National Personnel Records Center (NPRC) has identified some medical-related alternate records to reconstruct information lost in the 1973 fire, but these records are limited and not comprehensive. Most of the records in the supplementary file pertain to active duty Army and Army Air Corps personnel from 1942 to 1945 and active duty Army personnel from 1950 to 1954. NPRC utilizes approximately 7.8 million hospital admission abstracts to obtain supplementary information.

Any medical records of former active duty personnel filed with the Official Military Personnel File (OMPF) are considered part of that record and are maintained with it. NPRC needs the name of the hospital, month (if known) and year of treatment, as well as the veteran's name and Social Security or service number to locate these clinical records.

Information concerning "outpatient" Health Records is not specified in the provided paragraph. Army and Air Force records received prior to 1960 are an exception to the hospital-filing rule. Since 1960, NPRC has maintained these records in bulk accessions retired annually by the creating hospital, rather than with the individual personnel file. Clinical records, with the exception of Army and Air Force records received prior to 1960, are filed by the name of the hospital in which the service member was treated.

Army and Air Force Hospitals retain their records for one calendar year and Navy Hospitals retain their records for two calendar years before retirement to NPRC. All medical treatment records are temporary (non-permanent) records. This supplementary source does not cover all admissions during the related timeframes and has limited medical information. Navy clinical records have always been retired and maintained in this manner. There are small, scattered collections of records from years earlier than those listed above.

1. The complex system for military clinical records spans various branches of science in healthcare.
2. Service Treatment Records are held by the National Archives, which contains official military personnel records.
3. For VA medical records, there's an electronic system called "Blue Button," providing access to individual EHR.
4. FOIA requests can be made to the VA for medical and related personnel records.
5. MHS GENESIS is a centralized EHR system across military treatment facilities.
6. The Veterans Health Administration manage electronic and paper health information at VA facilities.
7. Community providers are contractually required to return medical records to the VA within 30 days of an appointment.
8. The Consolidated Toolbox documents and tracks the medical record retrieval process.
9. Records are stored electronically on magnetic media and cloud-based systems for backup and security.
10. Records related to veterans' care are maintained in VA medical centers, data processing centers, and Veterans Integrated Service Networks.
11. Backup data is stored in web-based cloud storage systems with security policies compliant with VA standards.
12. Records can be retrieved using personal identifiers such as name or Social Security Number.
13. Provider-related records require provider or institution identifiers.
14. Some specific records, such as those at the Automated Records Center, use SSN for retrieval.
15. Clinical Record Libraries in military hospitals may have records that were not filed in the OMPF and were not affected by the 1973 Fire.
16. Teaching hospitals that maintain Clinical Record Libraries may retain records up to 5 years before retirement.
17. Clinical (hospital inpatient) records are compiled when active duty members are hospitalized while in the service.
18. The National Personnel Records Center utilizes hospital admission abstracts to obtain supplementary information.
19. NPRC needs the name of the hospital, month (if known) and year of treatment, as well as the veteran's name and Social Security or service number to locate these clinical records.
20. Information concerning "outpatient" Health Records is not specifically mentioned in the provided paragraph.
21. Army and Air Force records received prior to 1960 are an exception to the hospital-filing rule.
22. Since 1960, NPRC has maintained these records in bulk accessions retired annually by the creating hospital.
23. Clinical records, with the exception of Army and Air Force records received prior to 1960, are filed by the name of the hospital in which the service member was treated.
24. Army and Air Force Hospitals retain their records for one calendar year, while Navy Hospitals retain their records for two calendar years before retirement.
25. Medical treatment records are temporary (non-permanent) records.
26. This supplementary source does not cover all admissions during the related timeframes and has limited medical information.
27. Naval clinical records have always been retired and maintained in this manner, with small, scattered collections of records from years earlier than those listed above.

In addition to the given words, the following related words were also used in the text: "hospitals," "military," "facilities," "government," "records," "health," "ehr," "va," "treatment," "medical," and "electronic."

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