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DoD Health Record

Date of Publication

6/8/2016

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 DoD health care system, each of which is a specific subset of the information in the DoD Health Record are the STR, 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 STR and 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 6040.42: Management Standards for Medical Coding for Health Records

Related Glossary Terms

DoD Health Record [DoDI 6040.45] | DoD Health Record

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