The operational capabilities employed by a record system to control the availability of information to individuals based on their position and responsibility within the organization.

Formerly the Nationwide Health Information Network Exchange. A community of organizations and health systems who share information under a common trust framework and a common set of rules. Participants include federal agencies, states, and health information organizations and health systems, which represent hundreds of hospitals, thousands of providers, a...

Personnel who, through a verification process, have presented a legitimate requirement to access medical records and been approved.

A unique 10-digit identifier assigned to each person who has a record in the Defense Eligibility and Enrollment Record System (DEERS) database, including all military personnel, family members, employees, most contractors. The Department of Defense (DoD) identification number identifies the individual in all interactions with DoD. Also known as the electr...

Chronology of outpatient medical, dental, and mental health care received by non-Service members and applies to anyone that does not meet the criteria for Service Treatment Record.

A unique identifier assigned to a beneficiary based on association with a Department of Defense sponsor and used to determine benefits. DoD beneficiaries who have multiple sponsors will be assigned unique DBNs for each relationship.

An entry in the record that is saved but not finally signed by the entering provider. Draft entries can be documents, notes, or other elements of the health record.

The foundation of the Service member’s longitudinal DoD Health Record. It includes the medical examination performed by the United States Military Entrance Processing Command (USMEPCOM) or Department of Defense Medical Exam Review Board (DoDMERB) personnel, including associated internal and external records (paper or digital), as required.

Specialty care consultation and referral reports, histories and physicals, progress notes, notes on episodes of care, and other patient information (such as laboratory reports, x-ray readings, operative reports), and discharge summaries for beneficiaries referred by an MTF, or reports of any other such care provided without a referral, in accordance with ...

An independent, not-for-profit organization that accredits and certifies more than 20,500 health care organizations and programs in the United States reflecting an organization’s commitment to meeting certain performance standards.

Notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and that are separated from the rest of the individual’s medical record.

A form used to indicate that a paper STR folder is complete. When uploaded to the electronic record archive, this form certifies that the STR is complete as of the form completion date. It is an administrative document added to an STR.

The identification and control of the risks arising from physical, chemical, and other workplace hazards to establish and maintain a safe and healthy working environment.

The electronic analog of a written signature used by a third party to determine that the entity named in the signature did sign the information. A digital signature is configured to automatically include a date and time and indicates that the information to which it is attached has not changed since the signing.

The occupational health record for all categories of DoD civil service workers, covered contractors, or other groups provided occupational health services by the DoD.