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.

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

The time during which a functional machine or system is not functioning properly or is otherwise unavailable to users.

The set of health care documentation recorded during a period of hospitalization.

The electronic medical record (EMR) system used by the DoD since its initial implementation in January 2004. Though the term has sometimes been described as an acronym (Armed Forces Health Longitudinal Application), the term itself is the correct name of the system.

Healthcare related management activities performed in accordance with References (i) DoD 5400.11-R, “Department of Defense Privacy Program,” May 14, 2007 and (k)   DoD 6025.18-R, “DoD Health Information Privacy Regulation,” January 24, 2003 and governed by the Privacy Rule defined in part 164 of Title 45, CFR.

Documents that are discovered unattached to a medical record folder (orphaned or loose flowing) or that are received or discovered after a record has been archived (late). Generally applied to documents pertaining to an Service treatment record (STR) and discovered in an MTF after the STR has been archived or sent away.

The authoritative data repository for identity information. DEERS will be used to verify an individual’s identity, affiliation with the Department of Defense, and eligibility for benefits, privileges, and entitlements.

Used to capture, index, display, or store the following types of documentation, which may be provided on paper, electronically, or on other media and can include: Paper documents not available in digital format. Digital images. Photos. Video files. Audio files (including but not limited to voicemails). Waveforms. Email.

In information systems, a non-hierarchical keyword or term assigned to a document or other piece of information. The entry of metadata information about a scanned document allows for categorization of the data so the document can subsequently be located.

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 E...

The provision of services to a patient that require some degree of interaction between the patient and the health care provider. Examples include assessment, performing procedures, teaching, and implementation of a care plan.

Computer analysis of the human voice, especially for the purposes of interpreting words and phrases or identifying an individual voice.

When using or disclosing protected health information (PHI) in any form or when requesting PHI from another covered entity, all reasonable efforts to limit the use, disclosure, or request of PHI to that necessary to accomplish the intended purpose of the use, disclosure, or request.

Legal document stating the patient’s oral and written instructions about future medical care, in the event that the patient is not able to communicate these instructions. Examples include a living will and do not resuscitate orders.