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DoD Health Record [DoDI 6040.45]

Date of Publication

11/16/2015

Definition

Includes all medical and dental care documentation, including mental health care documentation, that has been recorded for that individual. Information may be recorded and maintained in paper or electronic media. Three principal component records maintained within the Department of Defense (DoD0 health care system, each of which is a specific subset of the information in the DoD Health Record are the STR, non-Service treatment record (NSTR), and OHTR. Inpatient records are also a part of the DoD Health Record for an individual. Certain documents from an inpatient record are also included in the Service treatment record (STR) and occupational health civilian employee treatment record (OHTR). Administrative documents created to communicate copies of information contained in the health record to non-health care related activities are not part of the DoD Health Record.

Source of Definition

DoD Instruction 6040.45: DoD Health Record Life Cycle Management

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

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