SUBJECT: Requests involving records created at military medical facilities

1. Purpose. This memorandum issues and transmits instructions on requests involving records created at military medical facilities.

2. Applicability. The provisions of this memorandum apply to all personnel in reference service operations.

3. Instructions. Instructions for processing requests for records created at military medical facilities are contained in the Attachment. Because of its length, the material is divided into chapters. A Table of Contents is included for convenience. This memo is NOT intended to provide processing instructions for requests for medical records from the Department of Veterans Affairs (VA). For detailed instructions, technicians should consult the latest revision of NPRC 1865.38, Answering VA Form 3101 requests. Also, instructions are available in the latest revisions of NPRC 1865.103, Requests involving health records of former military members, and NPRC 1865.113, Organizational records searching procedures used in the Records Reconstruction Branch.

4. Forms. This memorandum provides for the use of the following forms.

NA Form 13013, File Chargeout Card
NA Form 13042, Request for Information Needed to Locate Medical Records
NA Form 13053, NPRC Acknowledgement/Referral
NA Form 13104, Multiple Purpose Correspondence Form
NA Form 13105, NPRC Search Request and Reply
NA Form 13151, Reply to Request for Organizational Records (Medical)
NARA Test Form (unnumbered), reference request facsimile (CIPS request)
Orange instruction sheet for completing DD Form 877 (unnumbered and untitled)
AF Form 42, Records Shipment List
AF Form 565-4, Clinical Record Cover Sheet
DA Form 2172, Records Shipment List
DA Form 3647, Clinical Record Cover Sheet
DD Form 728, Doctor's Orders
DD Form 877, Request for Medical/Dental Records or Information
DD Form 481, Clinical Record Cover Sheet
Standard Form 135, Records Transmittal and Receipt
Standard Form 180, Request Pertaining to Military Records
Standard Form 502, Clinical Record Narrative Summary
Standard Form 504, Medical Record - History
Standard Form 505, Medical Record - History
Standard Form 509, Medical Record - Progress Notes
Standard Form 510, Nursing Notes
Standard Form 511, Vital Signs Record
Standard Form 513, Clinical Record Consultation Sheet
Standard Form 514, Laboratory Reports
Standard Form 515, Tissue Examination
Standard Form 516, Operation Report
Standard Forms 519 and 519A, Radiologic Consultation Requests/Reports
Standard Form 539, Abbreviated Medical Record
Standard Form 541, Cynecologic Cytology
Standard Form 600, Chronological Record of Care
VA Form 3101, Request for Information
 

DAVID L. PETREE
Director

1. General.  Medical records created at military medical facilities include: clinical (hospital inpatient) records of former military personnel while on active duty; medical treatment records of military retirees and dependents (see par. 3, below); and mental health records (from Army and Air Force facilities only).

2. Inpatient records.  Inpatient (clinical) records are generally retired to NPRC by the facility which created them. Inpatient records are compiled when members are actually hospitalized while in the service. An overnight stay or admission generally makes a patient an inpatient. The resulting records from hospital care are called either clinical or inpatient records. Inpatient records are retained at the medical facility which compiled them for varying periods of time: normally one to two years, but up to five years for most clinical record libraries and up to ten years for a teaching hospital. The earliest clinical record collections at MPR are: Army - 1960; Air Force - 1957; and Navy - 1940's. Earlier Army and Air Force clinical records were filed in the OMPF, and many of the documents recording inpatient care for Army and Air Force veterans were destroyed in the 1973 fire. EXCEPTION: Clinical record library collections date from the early 1940's (see app. 2-D and NPRC 1865.113, fig. 2-7.2).

3. Medical treatment records of military retirees and dependents.

     a. Retirees.  For retirees, NPRC (MPR) stores records of inpatient, outpatient, dental, and mental health treatment. These records reflect health care for former members during their retirement years. Some record collections date from the 1940's and 1950's, but more comprehensive information exists beginning in the 1960's. The retiree records are sent to NPRC (MPR) from medical treatment facilities after 1-3 years of inactivity and are retained for 50 years from the year of last patient activity.

     b. Dependents.  For dependents, NPRC stores records of inpatient, outpatient, mental health treatment, and dental (Navy and Coast Guard only. Coast Guard dental records are combined with the outpatient record). MPR stores the records of individuals treated at Navy facilities; and CPR stores the records of individuals treated at Army and Air Force facilities. Some record collections date from the 1940's and 1950's, but more comprehensive information exists beginning in the 1960's. The records are sent to NPRC after 1-3 years of inactivity and are retained 50 years from the year of last patient activity with the exception of dependent dental records which are destroyed after 5 years.

4. Mental health records.  Army and Air Force medical treatment facilities retire mental health records to NPRC. These records include detailed psychiatric notations of consultation, tests, and treatment.

5. Responsibility.  Routine requests for records created by military medical facilities are handled by Records Reconstruction Branch, Correspondence Section 2, (NRPMR-O) at MPR; and Reference Service Branch, Personnel Reference Service Section, (NRPCR-P) at CPR. For more complete location information and descriptions of the records located at each building, see app. 1-A. For procedures in working cases involving both MPR and CPR, see NPRC 1865.103, subpar. 1-8d.

6. Release of information.  The release of information from and photocopies of military medical records is governed by special agreement between the Department of Defense and the National Archives and Records Administration. The specific items of the agreement are set forth in the latest revision of NPRC 1865.16, Release and Access Guide for Military Records. The same release policies and procedures that apply to health records containing potentially detrimental and confidential information also apply to records created by military medical facilities. See NPRC 1865.103, ch. 3.

7. Accounting of disclosure.  See the latest revision of NPRC1864.102, Privacy Act implementation in NPRC reference service operations, for an explanation of this requirement of the Privacy Act of 1974. NPRC branch personnel fulfill the requirement to keep an accounting of the disclosure by retaining a copy of the request and authorization in the record, along with the copy of our reply.

8. Requests for certified copies.  Follow procedures outlined in NPRC 1865.103, par. 3-13.

9. Information vital to search.  The following information is important for conducting a search:

     a. Identifying information.

(1) The patient's name at time of treatment and status; e.g., dependent or military retiree.

(2) The SSN of the military member or sponsor, NOT dependent (patient), is often absolutely necessary for records created after June 1969. Prior to that date, and through December 1971 for Navy and Marine Corps and September 1974 for Coast Guard, the military service number is needed. On occasion, an alphabetical list is available in order to conduct a search.

     c. Place where treatment occurred.  For inpatient records, the numerical designation; e.g., the 102nd Evacuation Hospital, and/or the city/country/base of the treatment facility is vital. Occasionally, the name of the hospital can be ascertained if the requester furnishes the town, state, APO/FPO, and country where treatment occurred. For outpatient records the last place of treatment is needed.

     d. Dates of treatment.  For inpatient records, the year(s) of treatment is/are usually sufficient, although specific dates are helpful at times. For outpatient records, the last year of treatment is needed. When a search of sick reports or morning reports will be required (most often in fire-related cases), more specific information is needed. See the latest revision of NPRC1865.113.

10. Vital Information not provided.  See NOTE below:

     a. Private sources.  If the information needed to conduct a search is not provided, return the inquiry to the requester using NA Form 13151, Reply to Request for Organizational Records (Medical), as the transmittal (see fig. 1-10.1). Complete the form to the extent possible and check the block that states, "Clinical records and mental hygiene consultation...." Attach NA Form 13042, Request for Information Needed to Locate Medical Records (see fig. 1-10.2). Circle in red or mark the items required for answering the request. Also highlight the line at the top of the form which states, "Please return this form and your original request." Check the appropriate "Return to" address and write in "NRPMR-O."

     b. VA Form 3101, Request for Information.  If the request is received on VA Form 3101, indicate in the remarks section the information needed, or attach NA Form 13042 and highlight the information needed to respond to the request. Also highlight the line at the top of form which states, "Please return this form and your original request."

     c. DD Form 877, Request for Medical/Dental Records or Information.  If the request is received on DD Form 877, check item 12 and indicate the information needed, and/or attach the orange instruction sheet that states, "Please Post for Reference" (see fig. 1-10.3 and fig. 1-10.4). This instruction sheet requires the medical treatment facility to provide the accession number, box number, location, and registry number, if applicable. Sign and date the DD Form 877 and place a check mark next to the address shown in item 19.

NOTE:For inpatient treatment only, if the place of treatment, patient's name, and veteran's/sponsor's SSN/SN are provided, and the date of treatment appears to be 1965 to the present, probe the Patient Retrieval System (PRS). (See subpar. 2-2a.)

1. Searching aids.  Generally, military service departments hold records created in military medical facilities for one to two years after the end of the year in which the last medical treatment was given before retiring the records to NPRC. For example, a clinical record from June 1978 would be retired to NPRC in January 1980. Inpatient records are retired by the year of admission. Outpatient records are retired by the year of last treatment. Listings of military medical facilities are provided in app. 2-A (Air Force), app. 2-B (Army), app. 2-C (Navy) and app 2-D (Clinical Record Libraries). Due to base closures, NPRC has received early shipments of records. The closed/pending closed bases are marked with an asterisk on the listings.

2. Using indexes to locate medical record shipments.  The first step in physically locating medical records is to use the appropriate index(es) to find the shipment in which the desired record would most likely be located. There are two systems which may be used to index records, one automated and one manual. The order in which one or both of these systems is used is dependent on the information provided in the request.

     a. Patient Retrieval System (PRS).  This system is a database containing information on inpatient admissions for service members (sponsors) and their dependents at Army, Navy, and Air Force medical facilities worldwide. Records on the PRS are available for Army facilities since 1970, Air Force facilities since 1971, and Navy facilities since 1965. Yearly updates are made to include current information. The information provided by requesters is often vague or inaccurate regarding the type, date, and place of treatment. The primary use of the PRS is to supplement and verify the information that has been provided by the requester. The PRS is a program which is activated by entering the social security number or service number (for earlier years) of the veteran/sponsor. When the SSN/SN is entered, the computer searches the database, and then displays data on both the sponsor and all of his/her dependents (see fig. 2-2.1). The data displayed includes the Hospital Registry Number, the Family Member Prefix (FMP) Code, the date of admission to the hospital, and the hospital code, name, and location. The information from the PRS is used to obtain records location information, see subpar. b, below. Actual instructions for accessing this system are provided separate from this directive by the supervisor. NOTE: Records shown on the PRS may not yet be retired to NPRC.

     b. Standard Form 135, Records Transmittal and Receipt.  This is a manual system located in boxes in the NRPMR-O office area. The boxes contain file folders labeled with the military hospital name and location. The file folders are alphabetically ordered. The method for using this system is to first locate the proper folder(s) from the information provided in the request. The Standard Form 135's (see fig. 2-2.2) are ordered in the folder with the most recent shipment (and year of treatment) on top. The SF 135's for all the various types of records are filed together, so care must be taken to read each SF 135 to determine the type of record it relates to; e.g., inpatient or outpatient. Care should also be exercised because there are often multiple shipments for the same year of treatment and for the same type of treatment. If treatment occurred prior to 1964, it may be necessary to check the SF 135's for each branch of service for that facility; e.g., Air Force or Navy personnel treated at Walter Reed Army Hospital check in Air Force and Navy indexes.

3. Filing and care of SF 135's.  SF 135's are the original document detailing the transfer of records from the treatment facility to NPRC. They must be carefully maintained and filed in the correct foldersin a timely manner. It is each employee's responsibility to see that torn documents are repaired.

4. Search of indexes.

     a. Navy medical facilities.

(1) Arrangement of finding aid folders.  Finding aid folders are arranged in alphabetical order by the name of the activity (city, hospital, and sometimes organizational unit) where treatment was given. Folders for ships are in a separate run. Finding aids for Navy and Marine Corps personnel and dependents treated in Army and Air Force hospitals are kept separate.

(2) Transfer documents.  Transfer documents, usually SF 135, are on the right side of the folder. Documents for inpatient records are followed by documents for outpatient records for the same year. Each inpatient/outpatient grouping is arranged in descending chronological order, from latest year to earliest. EXCEPTION:The inpatient and outpatient records for Bethesda Naval Hospital are in separate folders.

(3) Inpatient records.  Inpatient records are filed in register number order by appropriate activity and date of admission. The register number is obtained from an alphabetical index of patients, showing names of all persons admitted to the hospital during a specific time span, date of admission, and register number assigned to individual records. Beginning in the 1980's, the records are filed by terminal digit (see subpar. 8c).

(4) Outpatient records.  Outpatient records are filed in alphabetical order by appropriate activity and date of last treatment. Beginning in the 1980's, the records are filed by terminal digit.

(5) F cards.  F cards for years 1944 and 1945 have been microfilmed and show treatment given to Navy and Marine Corps personnel. They contain name, service number, rank, diagnosis, number of days sick, and disposition date. The film is available for use in the office of the National Research Council, Room 1793. Cards are arranged either numerically, with an alphabetical index, or in alphabetical order by the first four letters of the surname, then by first and middle name.

(1) Arrangement of finding aid folders.  Finding aid folders are arranged in alphabetical order by the name of the hospital or city of location. There is a separate run of numbered hospitals, clinics, etc., in numerical order; e.g., 25th Aviation Battalion Dispensary.

(2) Transfer documents.  Transfer documents are SF 135 or DA 2172, Records Shipment List. In some cases, transfer documents for inpatient records are on the right side of the folder, while those for outpatient, psychiatric, and dental records are on the left side. In other folders, documents for inpatient records for a given year are followed by those for outpatient records for the same year. In both cases, documents are arranged in descending chronological order, from the latest year to the earliest.

(3) Inpatient records.  Clinical records are filed alphabetically (1960's); or beginning in the 1970's by terminal digit method using the last four digits of the service number or SSN.

(1) Arrangement of finding aid folders.  Finding aid folders are arranged in alphabetical order by the name of the hospital or city of location. In box one there is an APO and a numerical index to overseas hospitals or detachments; e.g., 388 TAC Hosp or 377 USAF Hosp, giving city of location. That file may be found in the alphabetical listing.

(2) Transfer documents.  Transfer documents are SF 135 or AF Form 42, Records Shipment List. Transfer documents for inpatient records are on the right side of the folder, while those for outpatient, psychiatric, and dental records are on the left. Documents are arranged in descending chronological order, from the latest year to the earliest.

(3) Inpatient records.  Records are filed by registry number or alphabetically through 1990. Beginning in 1991, the records are filed by terminal digit.

     a. 04 = module

     b. 26 = row

     c. 07 = shelving unit (numbered North to South on odd rows and South to North on even rows)

     d. 5 = shelf level (descending order from top to bottom)

     e. 3 = box location (generally only first box in accession is marked)

NOTE: For numbers in old code; e.g., 28-1811, consult an archivist for new location number.

6. Scope of search.  While using the indexing systems, it is important not only to remember that the requester may not provide the correct information, but also that the hospital retiring the records may do so incorrectly. Therefore, the following rules will be used to index and search for records:

     a. Inpatient.  When searching for inpatient records, search the year of treatment given. If a request deals with inpatient treatment which occurred in the last three months of the year, and no record for the specified year is located, search the following year since sometimes records from the last three months are retired with records from the following year.  (See also subpar. 2a for using the PRS).

     b. Outpatient, dental, or psychiatric.  If the request states that outpatient, dental, or psychiatric records are needed, search the last year of treatment given.

     c. Both inpatient and outpatient.  If both inpatient and outpatient records are requested, and a range of treatment dates are given, search for the outpatient record first. If an outpatient record is located, screen it for copies of Clinical Record Cover Sheets, which will document inpatient treatment. If found in the record, the Cover Sheets will provide the date(s) and place(s) of inpatient treatment. These options involving extra indexing and searching will only be necessary, however, for inpatient records not identified using the PRS.

7. Shelving plans.  There are three distinct ways that record shipments are placed on shelving at NPRC.

     a. Front-only shelving.  Using this method, records are shelved only on the front spaces of each shelf. Other types of records, or other shipments of records, are placed on the back spaces. The front-only method is normally used for active records, such as Official Military Personnel Folders.

     b. Back-only shelving.  Using this method, records are shelved only on the back spaces of each shelf. Other types of records, or other shipments of records are placed on the front spaces. The back-only method is normally used for inactive records, such as dependent medical records.

     c. Standard shelving.  Using this method, the same type of records, or the same shipment of records, are placed on both the front and back spaces of each shelf. This type of shelving plan is normally used with large accessions or large runs of the same type of record.

8. Filing systems.  Once the desired shipment is located, there are several ways that the medical records could be organized in the box or boxes located.

     a. Alphabetically.  Records alphabetically organized will be by last name, and then by first name for records with the same last name. The individual boxes in the shipment will be labeled with the first name in each box or the range of names in each box.

     b. Clinical Registry Number (inpatient records only).  Inpatient records may be numerically organized by a five or six digit number. Usually, there is an alphabetically organized Register of Patients in the first box of the shipment. Locate the patient's name and obtain the Registry Number for the patient's record. The individual boxes in the shipment will be labeled with the run of Registry Numbers in each. To locate the record, locate the box with the correct range of numbers.

     c. Terminal digit.  Records may be ordered by using the last four digits of the veteran's/ sponsor's social security number. The individual boxes in the shipment will be labeled with the run of terminal digits in each. To locate the record, locate the box with the correct range of numbers.

9. Charging out records.  If the requested medical record is located, write the file location on the record after removing it from its box. If the request is on DD Form 877, the first carbon copy of the form is used as the chargeout. VA Form 3101 may also be used as the chargeout for clinical records. Otherwise, use NA Form 13013, File Chargeout Card, or the hard copy of the PRS printout, to charge the record out of file. Date and initial whatever form is used as the chargeout. If the medical record is to be photocopied only (see par. 3-4), write the "NRPMR-O" and the date tag code in the "Charged To" block. If the medical record is to be sent to an NPRC branch or another agency, write the branch office symbol or agency name in the "Charged To" block. The name and SN, SSN, or clinical registry number, as it appears on the medical record, is also transcribed on the chargeout. When records are withdrawn from more than one file location, place a charge out card in each location showing the location to which the records are being sent.

1. Types of search requests.  Search requests will be of two basic types: internal requests from correspondence operations; and external requests from outside NPRC seeking copies or originals of medical records. Regardless of the type of request, a copy of each response is placed in the section's transitory file.

2. Internal search requests.  Requests for inpatient and medical treatment records of military retirees and dependents are received from the correspondence operations in relation to a case that also requires copies of military personnel and/or health records from the Official Military Personnel Folder. Search requests are received on NA Form 13105, NPRC Search Request and Reply (see fig. 3-2), NA Form 13105 with PRS printouts attached, or a PRS printout (if only one record is being requested). The results of a search request for multiple records shall be kept together and returned to the requester as one response.

     a. Vital information not provided.  If all the information needed to conduct the search is not provided, return the request to the originating office. Annotate the information needed to conduct the search. Sign and date the form.

     b. Negative search.  If the search is negative, return the request to the originating office. Annotate the location(s) searched. Check or write "negative," sign, and date the form. If the records have not been retired to NPRC, the OR technician shall state that fact on the search request form.

     c. Positive search.  Return the request to the originating office. Attach the requested record(s), and sign and date the search request form.

3. External search requests.  Requests for inpatient and medical treatment records of military retirees and dependents are received from various external sources to include: private sources; e.g., veteran, physicians, hospitals, attorney's, and state agencies; and Federal government agencies; e.g., VA, and military medical treatment facilities. Request forms vary; e.g., letters, SF 180, Request Pertaining to Military Records, VA Form 3101, DD Form 877, or NARA Test Form (unnumbered), reference request facsimile generated by the Centers Information Processing System (CIPS), referred to as a "CIPS request" in the remainder of this memorandum.

     a. Vital information not furnished.  If all the information needed to conduct the search is not provided, follow procedures in par. 1-9.

     b. Negative search.

(1) Private sources.  Complete NA Form 13151. Report search attempts in the upper portion of the form referencing "Note 2" under "Results of Search" and circling "Note 2" in the "Results of Search" box (see fig. 3-3.1). If the records have not been retired to NPRC, circle "Note 3."

(2) VA Form 3101.  Complete remarks section by listing attempted searches and indicating no records found (see fig. 3-3.2). Sign and date the form.

(3) DD Form 877.  Check the block in item 12 indicating no records found. Sign and date the form (see fig. 3-3.3).

(4) CIPS request.  Check the appropriate block under "Results," and sign and date the form (see fig. 3-3.4).

NOTE: In order for a VA hospital or medical center to receive original medical records, they must request the records through a VARO, however, if an emergency request is received, copies may be sent.

4. Sending copies.  Each request for medical records should be thoroughly examined to determine what is specifically needed. In most cases, however, provide copies of the following documents:

     a. Inpatient records.

(1) Clinical Record Cover Sheet (may be DA Form 3647, DD Form 481, or AF Form 565-4).

(2) SF 516, Operation Report

(3) SF 515, Tissue Examination

(4) SF 502, Clinical Record Narrative Summary

Unless specifically requested, do not furnish the following:

SF 514, Laboratory Reports; SF 519 and 519A, Radiologic Consultation Requests/Reports; SF 510, Nursing Notes;
SF 511, Vital Signs Record; and SF 541, Cynecologic Cytology.

(See NPRC 1865.103, figs. 3-3.2, 3-3.3, 3-3.4 and 3-3.5 for samples of medical record documents.)

     b. Outpatient records.  Furnish every page of the outpatient record, which will most likely be SF 600, Chronological Record of Medical Care. DO NOT furnish other forms unless specifically requested.

     c. Non-military records.  Sometimes included with the inpatient or outpatient records are letters from non-military hospitals and private physicians, written in narrative form, and describing treatment given or diagnosis made. If it is determined that this information is pertinent to the request, furnish copies.

     d. Requests for x-rays.  X-rays are not normally available as part of the inpatient or outpatient records. Dental x-rays may be available in dental records, and these may be loaned to a physician or dentist. The normal response is to indicate on the response form that the type of x-ray requested is not maintained at NPRC.

     e. Deletion of third-party personal identifiers.  The Privacy Act permits an individual to gain access to his/her own records, and to grant access of these records to others. But if the record contains information of a sensitive nature about another individual, that portion cannot be made available to the subject of the record or his/her representative. This type of personal information would be social security numbers, home address or telephone number, financial transactions or medical history relating to persons other than the subject of the record.

     f. Transmittal.  Complete NA Form 13151. Check the first block and complete the top portion of the form that indicates the records searched. Reference "Note 1" under "Results of Search" and circle "Note 1" in the "Results of Search" box (also reference other appropriate "Notes" if multiple searches are performed). Place original of the form on top of the copies and rubberband or staple them together. File a copy of NA Form 13151 in the record with the request.

5. Sending original medical records.

     a. VA Form 3101.  Refer to the latest revision of NPRC 1865.38.

     b. Requests from military medical facilities.  Original medical treatment records are returned to military hospitals and clinics upon request. Requests are received on DD Form 877 or CIPS request. A separate request form must be submitted for each inpatient admission.

NOTE: No other sources are authorized to use these forms. Requests from an unauthorized source should be returned for resubmission on another appropriate form; e.g., SF 180.

(1) DD Form 877.  Stamp the folder with the "Return this record to:" stamp. Check appropriate boxes in items 8b and 12. Enter in the remarks section, "Return records to address shown in item 4." Make sure the address in item 4 is clearly shown and indicates the office symbol "NRPMR-O." Sign and date the form in items 13 and 14. Place a check mark next to the address in item 19. Place the original DD Form 877 on top of the folder(s) and rubberband together.

(2) CIPS request.  Follow procedures as outlined above, except complete the form as appropriate.

7. Reply when records have been sent to VA.  For requests from private sources, refer the requester to the VA using NA Form 13151. Reference "Note 4" under "Results of Search," circle "Note 4" in the "Results of Search" box, and provide the VA claim number. If the request is received on a DD Form 877 or CIPS request, indicate that the records were sent to the VA in the remarks/results section and provide the VA's phone number (1-800-827-1000) and the VA claim number.

8. Reply when records have been sent to another facility.  For requests from private sources, refer the requester to the facility using NA Form 13151. Reference "Note 5" under "Results of Search," circle "Note 5" in the "Results of Search" box, and provide the address of the facility in the space at the bottom of the form. If the request is received on DD Form 877 or CIPS request, indicate that the records are charged out and provide the address of the facility in the remarks/results section.

9. Subject of request a VA beneficiary.  If the subject of the request is receiving or has received treatment in a military medical facility subsequent to discharge (item 3 checked "VA Beneficiary"), and if the required record has not been transferred here, forward the request to the Office of Regional Records Services, Central Plains Region, (NREK) (formerly KC, FRC) using NA Form NA Form 13104, Multiple Purpose Correspondence Form. Notify requester of the referral using NA Form 13053, NPRC Acknowledgement/Referral. (See app. 1-A and/or Directory of Military Personnel and Related Records).