DoDI 6040.45, November 16, 2015; Incorporating Change 1 on April 11, 2017

Department of Defense

INSTRUCTION

NUMBER 6040.45

November 16, 2015

Incorporating Change 1, April 11, 2017

USD(P&R)

SUBJECT: DoD Health Record Life Cycle Management

References: See Enclosure 1

1. PURPOSE. In accordance with the authority in DoD Directive (DoDD) 5124.02 (Reference

(a)), this instruction reissues and retitles DoD Instruction (DoDI) 6040.45 (Reference (b)) to

establish policy, assign responsibilities, and prescribe procedures for DoD Health Record

management.

2. APPLICABILITY. This instruction applies to OSD, the Military Departments (including the

Coast Guard at all times, including when it is a Service in the Department of Homeland Security

by agreement with that Department), the Office of the Chairman of the Joint Chiefs of Staff and

the Joint Staff, the Combatant Commands, the Office of the Inspector General of the Department

of Defense (IG DoD), the Defense Agencies, the DoD Field Activities, and all other

organizational entities within the DoD (referred to collectively in this instruction as the “DoD

Components”).

3. POLICY. It is DoD policy that the DoD Health Record be created, used, maintained, shared,

stored, and dispositioned to ensure the maintenance of a complete and accurate health record for

beneficiaries in accordance with References (c) through (l).

a. The DoD Health Record is the property of the U.S. Government, not the beneficiary or the

beneficiary’s guardian. In accordance with section 552a of Title 5, United States Code (U.S.C.),

(also known and referred to in this instruction as “the Privacy Act of 1974” (Reference (m)) and

Public Law 104-191 (also known and referred to in this instruction as the “Health Insurance

Portability and Accountability Act (HIPAA)” (Reference (n)), the patient has the right to a copy

of the information in the DoD Health Record, as established and implemented in accordance

with References (h) through (k), unless specifically excepted by this instruction and supporting

implementation and procedural guidance.

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 2

b. Documentation of care performed at military treatment facilities (MTFs) must be

maintained in accordance with the National Archives and Records Administration (NARA)

approved disposition schedules and chapter 12 of Title 36, Code of Federal Regulations (CFR)

(Reference (c)). NARA-approved record disposition schedules (References (o) through (q))

determine the duration of storage of the DoD Health Record and its component records.

c. The information stored in the DoD Health Record must be made available to authorized

personnel of the Military Health System (MHS) to support the health care operations of the

MHS. This information must support continuity of care, medical facility accreditation

requirements, the Military Departments’ readiness, the graduate medical education programs of

the MHS, the Defense Health Agency (DHA) clinical coding and auditing actions, and other

missions as directed by the Assistant Secretary of Defense for Health Affairs (ASD(HA)).

d. Medical and dental records are established for every Service member. Such records are

also established for every DoD civilian employee involved in any occupational health matter and

for other health care beneficiaries as appropriate.

(1) Documentation of those records may be performed by licensed military, civilian, and

contractor personnel authorized by DoD.

(2) Healthcare practitioners and authorized personnel providing medical, dental, and

mental healthcare and services will ensure accurate and complete descriptions of all care and

services rendered are entered into the appropriate DoD Health Record for every individual

treated, using the designated primary electronic medical record (EMR) of the MHS whenever

possible.

(3) All documentation and entries into DoD Health Records must comply with

applicable standards established by accrediting organizations, such as The Joint Commission.

e. DoD Health Records are protected by the HIPAA Privacy, Breach Notification, and

Enforcement Rules in accordance with Reference (m) and DoDI 6025.18 (Reference (r)). DoD

Health Records maintained in digital form must be compliant with the HIPAA Security Rule in

accordance with DoDI 8580.02 (Reference (s)). DoD Health Records are also protected by the

Privacy Act (implemented at DoD through DoDD 5400.11 (Reference (h)) and DoD 6025.18-R

(Reference (k)).

4. RESPONSIBILITIES. See Enclosure 2.

5. PROCEDURES. See Enclosure 3.

6. RELEASABILITY. Cleared for public release. This instruction is available on the DoD

Issuances Website at http://www.dtic.mil/whs/directives.

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017

7. SUMMARY OF CHANGE 1. The changes to this issuance are administrative and update

URLs and references for accuracy.

8. EFFECTIVE DATE. This instruction is effective November 16, 2015.

Enclosures

1. References

2. Responsibilities

3. Procedures

Glossary

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 CONTENTS

TABLE OF CONTENTS

ENCLOSURE 1: REFERENCES ...................................................................................................5

ENCLOSURE 2: RESPONSIBILITIES .........................................................................................7

UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS

(USD(P&R)) ........................................................................................................................7

ASD(HA) ...................................................................................................................................7

DIRECTOR, DHA .....................................................................................................................8

ASSISTANT SECRETARY OF DEFENSE FOR MANPOWER AND RESERVE

AFFAIRS (ASD(M&RA)) ..................................................................................................8

IG DoD.......................................................................................................................................9

DoD COMPONENT HEADS....................................................................................................9

SECRETARIES OF THE MILITARY DEPARTMENTS AND COMMANDANT OF THE

U.S. COAST GUARD .........................................................................................................9

ENCLOSURE 3: PROCEDURES ................................................................................................10

DoD HEALTH RECORD COMPONENT RECORDS ..........................................................10

DOCUMENTATION INCLUDED IN THE DoD HEALTH RECORD ................................12

DoD HEALTH RECORD CREATION AND DOCUMENTATION.....................................14

DoD HEALTH RECORD CONFIDENTIALITY AND SAFEGUARDS ..............................17

EHR INFORMATION SHARING AND DISCLOSURE ......................................................17

RE-ENTRY OF FORMER SERVICE MEMBERS ................................................................19

DoD HEALTH RECORD USE ...............................................................................................20

DoD HEALTH RECORD MAINTENANCE AND STORAGE ............................................20

ACCESS TO DoD HEALTH RECORD AND PHI AND PII ................................................23

PATIENT IDENTITY MANAGEMENT ...............................................................................25

DoD HEALTH RECORD DISPOSITION ..............................................................................26

GLOSSARY ..................................................................................................................................27

PART I: ABBREVIATIONS AND ACRONYMS ................................................................27

PART II: DEFINITIONS ........................................................................................................28

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 ENCLOSURE 1

ENCLOSURE 1

REFERENCES

(a) DoD Directive 5124.02, “Under Secretary of Defense for Personnel and Readiness

(USD(P&R)),” June 23, 2008

(b) DoD Instruction 6040.45, “Service Treatment Record (STR) and Non-Service Treatment

Record (NSTR) Life Cycle Management,” October 28, 2010 (hereby cancelled)

(d) Memorandum of Understanding Between Department of Defense (DoD) and Department of

Veterans Affairs (VA), October 1995

(e) Public Law 110-181, “The National Defense Authorization Act for Fiscal Year 2008,”

January 28, 2008

(f) Public Law 113-66, “National Defense Authorization Act of 2014,” December 26, 2013

(g) DoD Instruction 5015.02, “DoD Records Management Program,” February 24, 2015

(h) DoD Directive 5400.11, “DoD Privacy Program,” October 29, 2014

(i) DoD 5400.11-R, “Department of Defense Privacy Program,” May 14, 2007

(j) DoD Instruction 1332.18, “Disability Evaluation System (DES),” August 5, 2014

(k) DoD 6025.18-R, “DoD Health Information Privacy Regulation,” January 24, 2003

(l) DoD Instruction 6040.42, “Management Standards for Medical Coding of DoD Health

Records,” June 8, 2016

(m) Section 552a of Title 5, United States Code (also known as “The Privacy Act of 1974”)

(n) Public Law 104-191, “Health Insurance Portability and Accountability Act (HIPAA),”

August 21, 1996

(o) National Archives and Record Administration Record Schedule N1- 330-10-003 “Service

Treatment Records (STR),” February 18, 2010

(p) National Archives and Record Administration Record Schedule N1- 330-01-002

“Consolidated Medical Records Schedule,” January 30, 2002

(q) National Archives and Record Administration Record Schedule N1- 330-11-003

“TRICARE Management Activity Systems,” November 30, 2010

(r) DoD Instruction 6025.18, “Privacy of Individually Identifiable Health Information in DoD

Health Care Programs,” December 2, 2009

(s) DoD Instruction 8580.02, “Security of Individually Identifiable Health Information in DoD

Health Care Programs,” August 12, 2015

(t) DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),”

September 30, 2013

(u) DoD Directive 5136.13, “Defense Health Agency (DHA),” September 30, 2013

(v) DoD Instruction 6400.01, “Family Advocacy Program (FAP),” February 13, 2015

(w) DoD Instruction 6495.02, “Sexual Assault Prevention and Response (SAPR) Program

Procedures,” March 28, 2013, as amended

(x) Part 2 of Title 42, Code of Federal Regulations

(y) Title 10, United States Code

(z) DoD Directive 6010.04, “Healthcare for the Uniformed Services Members and

Beneficiaries,” August 17, 2015

(aa) Title 32, Code of Federal Regulations

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(ab) Assistant Secretary of Defense for Health Affairs Memorandum, “Policy for the Clear and

Legible Report,” February 4, 2011

(ac) U.S. Department of Health and Human Services, Nationwide Health Information Network

Cooperative DURSA Team, “Data Use and Reciprocal Support Agreement (DURSA),”

November 16, 2009

(ad) Assistant Secretary of Defense for Health Affairs Memorandum, “Guidance for Requesting

Correction of Erroneously Entered Information in the Armed Services Longitudinal Health

Technology Application,” September 9, 2013

(ae) DoD Instruction 6055.05, “Occupational and Environmental Health (OEH),” November 11,

2008

(af) DoD Instruction 6055.01, “DoD Safety and Occupational Health (SOH) Program,”

October 14, 2014

(ag) DoD Instruction 6000.14, “DoD Patient Bill of Rights and Responsibilities in the Military

Health System (MHS),” September 26, 2011, as amended

(ah) Title 42, United States Code

(ai) DoD Instruction 1000.30, “Reduction of Social Security Number (SSN) Use Within DoD,”

August 1, 2012

(aj) Assistant Secretary of Defense for Health Affairs Memorandum, “Approval for Interim

Guidance for Use of the Healthcare Artifact and Image Management Solution (HAIMS)

Service Treatment Record and Clinical Use,” July 24, 2013

(ak) DoD Directive 5400.07, “DoD Freedom of Information Act (FOIA) Program,” January 2,

2008, as amended

(al) DoD Instruction 1000.25, “DoD Personnel Identity Protection (PIP) Program,” March 2,

2016

(am) Title 45, Code of Federal Regulations

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 ENCLOSURE 2

ENCLOSURE 2

RESPONSIBILITIES

1. UNDER SECRETARY OF DEFENSE FOR PERSONNEL AND READINESS

(USD(P&R)). The USD(P&R):

a. Prescribes the policies, requirements, and responsibilities for the information life-cycle

management of the DoD Health Record, Service Treatment Record (STR), Non-Service

Treatment Record (NSTR), and Occupational Health Civilian Employee Treatment Record

(OHTR), which apply regardless of media (printed or electronic) in which the information is

recorded. Determines procedures for the release of STR information from the DoD to other

federal agencies with which records are shared or transferred, such as the Department of

Veterans Affairs (VA) and other organizations authorized by law.

b. Oversees the implementation of and compliance with this instruction.

2. ASD(HA). Under the authority, direction, and control of the USD(P&R), the ASD(HA):

a. Oversees the Director, DHA, in the execution of programmatic and operational

responsibilities in accordance with DoDD 5136.01 (Reference (t)).

b. Develops and coordinates joint policy guidance and implementation instructions as

needed.

c. Facilitates provision of the DoD Health Record and the STR, NSTR, and OHTR to DoD

Components, to the VA, and to partner health care systems in accordance with HIPAA and DHA

approved memoranda of understanding. The memoranda are coordinated with the Military

Services to ensure that all subordinate medical organizations have access to the electronic

systems necessary for compiling and digitizing the paper portions of the DoD Health Record.

d. Facilitates transfer of the DoD Health Record and STR information and data from the

Military Services by granting access to enterprise-wide systems to other agencies in accordance

with law and in support of continuity of health care and Service members’ and veterans’

entitlement and benefits processing.

e. Coordinates improvement and reengineering of DoD Health Record and STR, NSTR, and

OHTR information management processes with the Secretaries of the Military Departments to

enable efficient and effective business practices and continuous evaluation within the DoD.

f. Coordinates with the Commander, U.S. Military Entrance Processing Command

(USMEPCOM) and the Director, DoD Medical Exam Review Board (DoDMERB) to develop

and implement life cycle management of the medical qualification records and medical

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 ENCLOSURE 2

information related to Service accessions in accordance with the procedures in Enclosure 3 of

this instruction.

g. Appoints MHS representatives, as needed, to all existing or newly developed work

groups created by the Joint Executive Council or the Office of the National Coordinator Federal

Health Architecture Management Board to identify and address emerging issues associated with

DoD Health Record and STR, NSTR, and OHTR management.

3. DIRECTOR, DHA. Under the authority, direction, and control of the ASD(HA) and

USD(P&R) and in addition to the responsibilities in section 6 of this enclosure, the Director,

DHA, consistent with DoDD 5136.13 (Reference (u)):

a. Establishes a formal joint DoD Health Record Management Program, providing financial

and personnel resources to monitor performance and compliance with this instruction, in

coordination with the Military Departments.

b. Ensures that the enterprise electronic systems supporting the DoD Health Record and

STR, NSTR, and OHTR are managed and sustained in accordance with DoDI 5015.02

(Reference (g)).

c. Ensures that the STR, NSTR, and OHTR contain the minimum core elements in

accordance with Reference (g) and DoDI 6040.42 (Reference (l)).

d. Ensures that the STR archiving systems makes the STR available to the VA according to

official memoranda of agreement or understanding between the DoD and VA and consistent with

legal requirements.

e. Develops and issues implementation and procedural guidance in accordance with

Reference (u) to specify documentation and management procedures for record systems that

support the STR and other components of the DoD Health Record.

f. Ensures electronic systems containing elements of the DoD Health Record have

disposition schedules approved by NARA.

4. ASSISTANT SECRETARY OF DEFENSE FOR MANPOWER AND RESERVE AFFAIRS

(ASD(M&RA)). Under the authority, direction, and control of the USD(P&R), the

ASD(M&RA) ensures that the Commander, USMEPCOM, implements life cycle management

of the medical qualification records, STR data (prior military service), or medical information

related to the Service accessions in accordance with the procedures in Enclosure 3 of this

instruction.

DoDI 6040.45, November 16, 2015

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5. IG DoD. In addition to the responsibilities in section 6 of this enclosure, the IG DoD:

a. Monitors the other DoD Components’ compliance with this instruction and conducts

inspections as deemed appropriate on the DoD Health Record and STR, NSTR, and OHTR life

cycle management.

b. May provide inspection reports and suggestions for resolution of issues to the USD(P&R)

and the DoD Component heads.

6. DoD COMPONENT HEADS. The DoD Component heads establish a DoD Health Record

Management Program that:

a. Adheres to the standards prescribed in References (g), (k), and (l) and the procedures

detailed in Enclosure 3 of this instruction.

b. Creates, maintains, uses, preserves as needed, and disposes of the DoD Health Record and

STR, NSTR, and OHTR to support routine DoD business operations and mission.

7. SECRETARIES OF THE MILITARY DEPARTMENTS AND COMMANDANT OF THE

U.S. COAST GUARD. In addition to the responsibilities in section 6 of this enclosure, the

Secretaries of the Military Departments and the Commandant of the U.S. Coast Guard:

a. Update the respective Military Department regulations for DoD Health Records or

develop new regulations in accordance with this instruction.

b. Develop and implement policy and procedural guidance in accordance with this

instruction and ensure that subordinate medical organizations have the necessary resources to

comply with medical records procedures as detailed in Enclosure 3 of this instruction.

c. Establish a position and ensure that it is appropriately resourced to function as a liaison

with federal agencies including the VA, to answer requests for active, Reserve, and National

Guard personnel or their designated beneficiaries in regards to DoD Health Records and STRs.

d. Provide facilities responsible for DoD Health Record maintenance, in particular those

responsible for the digitization of the STR, access to up to date rosters of individuals anticipating

separation from military service weekly when possible but not less than monthly. .

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 ENCLOSURE 3

ENCLOSURE 3

PROCEDURES

1. DoD HEALTH RECORD COMPONENT RECORDS

a. The DoD Health Record includes component records that are subsets of the entire medical

record for a person. The component records include the STR, the NSTR, and the OHTR. Each

component record is a defined subset of the DoD Health Record to serve a specific purpose. The

type of component record is principally determined by beneficiary category: Service member,

DoD civilian employee (for occupational health purposes), and non-active duty beneficiary.

b. The STR:

(1) Includes all of the essential information necessary for continuity of care,

determination of medical readiness, and determination of benefits for a member of any of the

Military Services. It is a principal component record of the DoD Health Record for the Service

member.

(2) Integrates applicable industrial hygiene, environmental hazards, and safety

information across the full range of military operations and operational environments.

(a) The STR is used for patient care, medico-legal support, benefits adjudication

(including, but not limited to, disability compensation benefits payments as described in DoDI

1332.18 (Reference (j)), billing, and certain other authorized purposes.

(b) The STR includes all documentation regardless of media format (paper or

electronic) as captured in a composite record produced by the DoD EMR system (for example

the Armed Forces Health Longitudinal Technology Application (AHLTA) Web-Print file),

reports of all TRICARE and contracted care received, any inpatient discharge summaries,

documentation of all shipboard care, and summaries of all care documented in the theater record

systems.

military career (e.g., discharge, separation, retirement, or death).

(3) Is used for tracking and determining force medical readiness and force health

protection requirements, as described in section C7.11 of Reference (k). It supports standardized

personnel administrative functions related to medical readiness determinations, case

management, individual medical readiness tracking, special duty qualifications, theater location

reporting requirements, public health and environmental incidents, longitudinal health status

tracking, registries, and related medical status determination needs of both active duty and

Reserve Components.

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 ENCLOSURE 3

(4) Includes documentation of care performed in operational environments, for example

shipboard and battlefield care. Information from the systems used to document that care will be

integrated or copied into the primary record systems that comprise the STR.

(a) The Military Services will develop, publish, and implement procedures to

integrate the medical, dental, and mental health care documentation generated at all theaters of

operation and contingency operation locations with the member’s DoD Health Record and STR.

Summary documents designed to include all information from a period of service in an

operational environment essential to continuity of care and future benefits determination, as

determined by the Service, may be used to meet this requirement.

(b) Any paper medical, dental, or mental health records generated at all theaters and

contingency operation locations will be collected and transferred to the Deployment Medical

Records Processing Center, Patient Administration Systems and Biostatistics Activity, Fort Sam

Houston, Texas, for scanning. These documents will be made available as images through an

electronic document management system that is integrated with the EMR, until complete

integration of this documentation into the electronic record systems comprising the STR is

achieved. The paper elements will be integrated with the member’s DoD Health Record and

STR located at their permanent duty station and Reserve and Guard units until the record is

accessible in electronic medium.

(5) Is determined to be complete when a Service member has separated from active

service and the archived copy of the record has been reviewed to ensure that it includes all

required elements. A completed DD Form 2963, “Service Treatment Record (STR)

Certification,” may be added to a paper STR folder to indicate that all available paper

documentation has been included as part of the archiving process. When the paper STR folder

has been scanned and uploaded into the electronic archiving system, the DD Form 2963 is then

separately uploaded to the electronic record archive, indicating that the electronic archive

constitutes a complete STR. The DD Form 2963 is the last document to be uploaded when

archiving the STR.

c. The Military Services will:

(1) Develop procedures to ensure that the STR is compiled into an archival copy and

stored in a repository made available to the VA within agreed upon timelines (based upon the

date of separation of an active duty Service member or receipt of a valid VA benefits claim on a

Reserve Component member) and in accordance with section 525 of Public Law 113-66

(Reference (f)).

(2) Collaborate with the DHA-designated office to develop standard checklists for STR

quality assurance and completeness.

(3) Establish procedures for documenting all activities taken to ensure a Service

member’s STR is complete and accurate at the time of the Service member’s separation or

retirement.

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(4) Establish custodial duties for STRs as the responsibility of the MTF where the

member is enrolled and receives primary care, regardless of member’s Service affiliation. For

Reserve Component members, the Services will develop agreements for STR custodial

responsibilities.

(5) Coordinate with the DHA to formalize policy and procedures to document

completion of annual reviews of the STR and provide the Service member an opportunity to

review key elements of the record, such as the problem list and documentation of care performed

outside of the MHS. Where the annual review indicates that an STR is incomplete, the Military

Services will develop processes to document the steps taken to remediate an incomplete STR.

d. The NSTR adheres to the same standards of health care documentation as the STR, but is

created and maintained for beneficiaries other than active duty Service members.

e. The OHTR will contain all medical, dental, and required environmental, safety, and

industrial hygiene data documentation related to an individual’s employment during all periods

of health system involvement.

(1) For an active duty Service member, this information is included in the STR.

(2) For a DoD civilian employee who receives health care in DoD facilities, the OHTR

documentation may be maintained in the same record system as the NSTR.

(3) The system must support an output of the information pertaining to the OHTR

without also disclosing non-OHTR information. That is, the system must be capable of an output

that includes only the OHTR information.

2. DOCUMENTATION INCLUDED IN THE DoD HEALTH RECORD

a. Mental health documentation is included in the DoD Health Record, unless specifically

excepted due to its sensitive nature, and not necessary for continuity of care.

(1) An example of excepted documentation is psychotherapy notes, which may include

detailed psychiatric notations of evaluations and consultations provided on an outpatient or

inpatient basis.

(2) Mental health care documentation included in the DoD Health Record must convey

the information necessary to support the diagnosis, treatment plan, and appropriate patient

disposition made by the mental health care professional.

(3) Such documentation supports continuity of health care in collaboration with ongoing

medical-surgical care across the boundaries of time, space, and varying medical, surgical, and

behavioral health specialty providers. Elements pertaining to mental health care that must be

documented in the DoD Health Record include:

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(a) Medication prescription and monitoring.

(b) Counseling session start and stop times.

(d) Results of clinical tests.

(e) Any summary of diagnosis, functional status, the treatment plan, symptoms,

prognosis, and progress to date.

b. Working materials, including notes and papers, used by a provider to complete a final

report for an individual patient are not part of the DoD Health Record unless they need to be

made available to others providing medical or dental care to that patient. Examples of working

materials that are not part of the DoD Health Record include, but are not limited to:

(1) Mental health assessment instruments.

(2) Psychotherapy notes.

(3) Paper forms used in clinical work flows, when the substantive information they help

acquire is transcribed into the digital documentation of that encounter.

c. The Family Advocacy Program records are not part of the DoD Health Records. These

records contain detailed confidential information regarding alleged or verified family

maltreatment in accordance with DoDI 6400.01 (Reference (v)). Reference in the DoD Health

Record to the events that led to referral to the Family Advocacy Program may be necessary to

assure continuity of care when treatment is required. Summary documentation provided by the

Family Advocacy Program may be used for this purpose; however, protected health information

(PHI) or personally identifiable information (PII) of other family members may not be included

in the DoD Health Record of the individual receiving health care.

d. Sexual assault forensic examination reports are not included in any component of the DoD

Health Record. Clinically relevant documentation of care provided to victims of sexual assault is

part of the DoD Health Record in accordance with DoDI 6495.02 (Reference (w)).

e. In accordance with part 2 of Title 42, CFR (Reference (x)), records of application to or

treatment in substance abuse program(s) are protected from public disclosure and only releasable

under the circumstances listed in Reference (x). These records are not included in any

component of the DoD Health Record, though documentation of related medical conditions will

be recorded in the DoD Health Record, as may be necessary for safe and proper health care.

f. Audio files generated as a result of a patient encounter or developed during treatment of a

patient may be captured by the electronic document management system. Examples include, but

are not limited to:

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(1) Digital Dictation. Once digital dictation is captured in transcript form and the

integrity of the transcript verified, the digital dictation may be destroyed.

(2) Voice Recognition (Where Enabled). Military Services will develop procedures for

verification of transcribed elements. The provider must verify the transcription.

g. Medical and dental information provided by the patient from other healthcare providers,

facilities, or devices will be captured or recorded in the electronic health record (EHR) or

document management system at the discretion of a health care provider or authorized medical

record administrator.

h. Medical department personnel will note the existence of an advance directive in the DoD

Health Record in accordance with Service-specific guidance. Appropriate metadata tags will

identify advance directive documents when they are captured in the electronic document

management system. Section 1044c of Title 10, U.S.C. (Reference (y)) provides for military

advance medical directives that are exempt from any requirements of form, substance, formality,

or recording required by State law.

i. When provided by the patient, the documents comprising a power of attorney will be

maintained with the other administrative documents in the record. Paper documents will be

appropriately digitized and metadata tagged in the electronic document management system.

After discharge, the patient may take any original paper documents and return the documents if

admitted again at some future date if required by Service policy.

3. DoD HEALTH RECORD CREATION AND DOCUMENTATION

a. The DoD Health Record is initiated as one of the component records described in section

1 of this enclosure either upon accession into the Service or upon the first presentation to a DoD

medical facility for health care.

b. For Service members, the initial elements of the DoD Health Record include the medical

examination performed by USMEPCOM or DoDMERB personnel, including associated DoD

and non-DoD health care documentation in paper or digital format, as required. The accession

medical record serves as the foundation of the Service member’s STR.

c. Eligibility for medical and dental benefits is determined in accordance with

DoDD 6010.04 (Reference (z)) and part 199 of Title 32, CFR (Reference (aa)). DoD MTF

personnel are responsible for verifying eligibility and providing care in accordance with the

beneficiary entitlement.

d. The OHTR for DoD civilian employees is created at the first medical encounter after

employment begins.

e. The OHTR for DoD-covered contractors is created at the first medical encounter after

their contract begins.

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f. The NSTR for DoD family members is created at the MTF or where the beneficiary is first

seen.

g. MTFs will establish procedures to ensure that only personnel with specifically designated

permissions may make entries in the DoD Health Record. All personnel will receive training in

accordance with References (k) and (r). Those designated personnel must comply with the

standards for record entry as described in this instruction.

h. Entries in medical, dental, and mental health records must contain information to:

(1) Identify the patient.

(2) Support the diagnosis and condition.

(3) Justify the care, treatment, and service rendered.

(4) Accurately document the results of care, treatment, and service rendered.

(5) Support continuity of care.

i. Health care personnel making authorized entries in the electronic DoD Health Record use

digital signatures to uniquely associate the signer with the document’s contents, ensuring data

integrity and non-repudiation of the electronic transaction. Any document generated and signed

electronically that is subsequently printed does not require an additional handwritten signature.

j. Handwritten signatures with dates are required for each entry and for any documentation

generated and signed exclusively in paper format. Editing of documentation in the paper record

requires a single line through the erroneous entry; the new entry is written including date, time,

and initials with a brief note as to why it was changed, such as Entry Error, Wrong Chart, Late

Entry.

k. All notes made in a patient’s DoD Health Record describing treatment or counseling will

be completed by health care providers who have either directly or indirectly provided care to that

patient. Documentation of indirect care is made when, for example, a provider is asked to

consult on a patient, review data from the record, and enter a comment based on the review

without interacting directly with the patient.

l. Entries in the DoD Health Record used to describe an interaction with a patient during the

course of treatment, generally referred to as Progress Notes, will comply with the standard

“Subjective, Objective, Assessment, and Plan” note format. EMR templates conforming to this

outline will be used whenever possible.

m. Documentation of medical, dental, and mental health care provided at an MTF that

cannot be entered through direct use of the primary EMR system will be captured and

maintained on forms that are specified by Service level instructions, either on paper or in

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electronic form. When possible, documents created in this manner will be uploaded into the

electronic document management system to be included as part of the DoD Health Record.

These documents need not be appended to notes written in the primary EMR system, but should

be associated with such entries as supported by the system. Once digitized and verified, the

original document may be destroyed in accordance with NARA disposition schedules

(References (o) through (q)). If inclusion into the electronic document management system is

not possible, paper documentation must be maintained in accordance with Service instructions

and References (k) and (r).

n. Artifacts created by supplemental documentation systems, such as electrocardiogram

tracings and other reports of medical testing or procedures, including both reports printed on

paper and electronic file formats, will be incorporated into the DoD Health Record by use of a

DoD-approved electronic document management system whenever possible. The document

management system must be sufficiently integrated with the EMR to ensure access to all

clinicians and administrators responsible for the kind of information contained in the artifact.

Military Service level instructions will govern the management of such artifacts when they are

maintained in paper format, and must be in compliance with STR procedures in this instruction.

o. In accordance with the ASD(HA) Memorandum (Reference (ab)), DoD organizations

maintaining DoD Health Records must ensure that documentation delivered to them by partner

organizations or by individual patients of medical, dental, and mental health care provided by

non-DoD practitioners, referred to as consult reports or clear and legible reports, are filed with

the patient’s medical or dental record, as appropriate. These records must be individually stored

or digitized in the electronic document management system.

p. Clinicians writing notes in the DoD Health Record that include any references to reports,

images, or artifacts that are not contained within the documentation being generated must

indicate, at a minimum, the section of the record or the system in which the referenced reports,

images, or artifacts reside.

q. Pre-natal care documentation is included in the DoD Health Record of the mother. After

the birth of an infant and establishment of the infant’s record, copies of documentation of care

from the infant’s prenatal period may be added to the infant’s record.

r. In accordance with DoD 5400.11-R (Reference (i)), patients and their authorized

representatives have the right to access their DoD Health Records and request amendment, if

they think the documentation is in error. The request to amend the record must be made in

writing and be signed by the patient or authorized representative. While the medical department

is not obligated to make the requested change, it is obligated to review the request, and act upon

it in accordance with the timeframes in Reference (i).

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4. DoD HEALTH RECORD CONFIDENTIALITY AND SAFEGUARDS

a. In addition to the confidentiality safeguards required by Reference (k), safeguards will be

instituted to maintain compliance with any other applicable confidentiality requirements under

law or DoD policy.

b. The Military Services will develop policies and procedures for defining levels of access to

paper and digital health information at all locations where such access is necessary. Access for

individuals or groups of individuals (work centers) must be based on requirements for fulfillment

of assigned duties and in accordance with law and DoD policy.

c. DoD Health Record management policies and procedures will support the creation,

maintenance, use, sharing, storage, and disposition of a complete and accurate DoD Health

Record for patients in accordance with References (g), (k), and (s).

d. DoD Health Records in paper and digital form are protected by the HIPAA Privacy,

Breach Notification, and Enforcement Rules as described in Reference (k). Additionally, DoD

Health Records maintained in digital form (with the possible exception of the OHTR) are subject

to the HIPAA Security Rule as described in Reference (s). Collectively known as the HIPAA

Rules, these requirements are implemented throughout the DoD by References (k) and (s). In

addition to the HIPAA Rules, the Privacy Act (implemented at DoD through References (h) and

(i)) also protects DoD Health Records.

e. Record entries may include draft and final entries. A draft entry will be indicated as draft

and may not be accessible to other clinicians. An entry made in the DoD Health Record that is

left in draft form beyond a specified period of time may be closed out so that it can be accessed

by other record users, either by an administrator who has been given such permission by the

MTF commander, or by another clinician with permissions to enter the same kind of information

that has been left in a draft form. Entries made final in this manner will be distinguishable from

regularly signed final entries. The length of time that entries may remain in draft form due to

prolonged unavailability of the entering provider may be defined by Service level instruction, but

will not exceed 30 days.

f. The Military Services will establish procedures to identify and safeguard medical

information designated as sensitive due to the content or a patient’s special status (e.g., President,

Special Operations) to facilitate additional precautions against improper or inadvertent

disclosures to users with limited DoD Health Record access.

5. EHR INFORMATION SHARING AND DISCLOSURE

a. DoD Health Records are subject to the following procedures related to health information

exchange. All personnel having access to the DoD Health Record will at a minimum protect the

privacy of PHI and PII, in accordance with References (h), (i), (k), and (r).

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(1) Organizations that share electronic health data with the MHS through the health

exchange protocols established or endorsed by the Health and Human Services Office of the

National Coordinator, referred to as the eHealth Exchange, must abide by the privacy and

security provisions of the Data Use and Reciprocal Support Agreement (Reference (ac)) or other

applicable agreement.

(2) Organizations that are not a part of the eHealth Exchange that wish to engage in

health information exchange with the MHS must enter into an agreement with the MHS that

specifies privacy and security requirements. The agreement must address re-disclosure of the

data received by the organization.

(3) If an outside organization seeks access to MHS EHR systems, such access will be

allowed only to the extent permitted by the Privacy Act and References (h), (i), (r), and (s), and

only after entering into agreement with the MHS approved by the DHA. Such agreement

requires the organization to abide by MHS system protections for sensitive information, and

requires periodic auditing as to whether, and to what extent, sensitive information has been

requested.

(4) When preparing DoD Health Record elements for electronic exchange, appropriate

procedures must be followed with respect to sensitive information. Sensitive health information,

regardless of its format, may be specifically labeled or segmented within the DoD Health

Record. Appropriate physical and, when technically feasible, electronic access controls, such as

auditing use, must be implemented to prevent unauthorized or inadvertent access to, or

transmission of, sensitive health information in paper and digital formats.

(5) The Military Services will develop procedures for responding to requests for

electronic health information access in accordance with Reference (g) and any other DoD policy

describing the circumstances in which PHI may be disclosed.

b. The MHS shares the health information of active duty and non-active duty individuals

through health information exchanges (HIE) in which MHS participates. Information sharing

includes publishing PHI to the HIE and subscribing to PHI from other HIE participants.

(1) Active duty personnel cannot limit MHS subscription to their PHI. For example,

active duty personnel cannot restrict sharing of their PHI with the MHS by opting out through an

eHealth Exchange participant.

(2) Active duty personnel cannot opt out of MHS publishing their PHI to an HIE.

(3) The MHS must advise active duty personnel that for reasons of medical readiness,

the MHS shares their PHI bi-directionally through HIE, with opting out available only to non-

active duty beneficiaries.

(4) The Military Services will develop policy and procedures for medical department

compliance with the current NARA disposition schedule (Reference (q)). This guidance

includes appropriate procedures to manage non-Service member beneficiary opt-out requests.

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c. When information is shared through electronic exchanges, management controls, such as

limiting the permissions given to specific users or requiring additional acknowledgements by

users, will be employed to avoid undermining the additional precautions taken to safeguard

entries designated as particularly sensitive.

d. In accordance with References (i) and (k), DoD Health Records personnel must provide

beneficiaries or their authorized representative copies of medical documentation in their DoD

Health Record when requested. The documentation will be provided in either paper or digital

format as specified by the beneficiary or authorized representative. If the documentation is

provided in digital format, Military Services must ensure their facility is in compliance with

HIPAA in accordance with References (k) and (r) and DoD policies in regard to format and

method of transmission to the beneficiary.

6. RE-ENTRY OF FORMER SERVICE MEMBERS

a. When a Service member has been discharged from military service and decides to re-enter

(re-enlist), or is recalled from retirement to active duty, the DHA will support the agency

performing the entrance evaluation (USMEPCOM, DoDMERB, or the gaining unit’s oversight

Command Surgeon’s office) by coordinating access to records for review of the re-entering

Service member’s health history, to include:

(1) Any past STR, OHTR, or NSTR.

(2) Any available documentation of medical, mental health, or dental care received from

non-DoD care providers, including the VA.

b. For former Service members who were discharged before January 1, 2014, requests for

past STRs are submitted to the VA in accordance with the Memorandum of Understanding

(Reference (d)). For former Service members who were discharged on or after January 1, 2014,

the past STRs, once processed, will be obtainable from the electronic repository established to

archive STRs. For former Service members with more than one previous discharge, requests

may need to be made to the VA and other DoD Components to obtain all past STRs.

c. The agency performing the entrance evaluation for re-entry will provide available past

STRs and other medical records that were reviewed along with the new accession medical

documents, in paper or electronic format, for inclusion in a new DoD Health Record. If the

technical capability is available, the agency will digitize relevant portions of available past STRs

that are in paper format and all new accession medical documents. The Military Services will

develop procedures to incorporate information provided in electronic format and for digitization

of any paper elements provided into an electronic document management system when available.

d. The Military Services must develop procedures for converting paper DoD Health Records

to digital for Service members and beneficiaries transferring between Military Services.

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e. The Military Services must develop processes and publish guidance about how to

incorporate past paper STRs into the electronic document management system in digital format.

7. DoD HEALTH RECORD USE

a. Medical personnel documenting direct patient care services make their entries into the

DoD Health Record at the time of observation, treatment, or care. Indirect services such as case

reviews, consults, record reviews, record corrections, documenting late and loose-flowing (LLF)

documents, and entries for care evaluations without face-to-face contact are allowed to the extent

permitted by DoD and Service policy. Indirect entries will be clearly marked as to the nature of

service provided or action taken relative to the DoD Health Record.

b. If a printed copy of the DoD Health Record or elements thereof are required, that printed

copy must be assembled in the order described for that specific purpose in a Military Service

guidance.

c. Legal correction of erroneous data is currently governed by the ASD(HA) Memorandum

(Reference (ad)). Medical departments will implement procedures in compliance with Reference

(ad), this instruction, or DHA procedural guidance.

8. DoD HEALTH RECORD MAINTENANCE AND STORAGE

a. When medical documentation must be made on paper, and that documentation may be

required for subsequent care, evaluation, or benefits determination of the patient, the

documentation must be captured and verified in the electronic document management system. If

the paper documentation is not required for observation, treatment, or care of the patient, it will

be managed in accordance with Reference (g) and the current NARA disposition guidance.

b. The electronic document management system must be used for the processing of artifacts

and documents that are to be included in the DoD Health Record. The following types of

documentation, which may be provided on paper, digitally, or other media, may be captured,

indexed, displayed, and stored in the electronic document management system:

(1) Paper documents not previously rendered in digital format.

(2) Digital images.

(3) Photographs.

(4) Video files.

(5) Audio files (including but not limited to voicemails and digital dictation).

(6) Waveforms.

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(7) Email.

c. Paper records may be required to support continuity of care for missions that cannot be

supported by electronic record systems. The Military Services will develop policy and

procedures for the storage of such paper records in medical unit health record storage facilities in

accordance with References (g) and (k). When possible, and in all cases within 45 business days

following separation of the member from Military Service, such paper records will be digitized

and uploaded into the electronic document management system.

d. Paper records may be dispositioned after capture in the electronic document management

system in accordance with NARA policy and Reference (g).

e. Military Services must develop policy and procedures for amendments or corrections to

the components of the DoD Health Record contained within the electronic document

management system. Amendments and corrections will be made at the time that inconsistencies

are noted, to the extent possible.

f. DoD Health Record documentation provided electronically or on media other than paper

may be destroyed after its conversion to the appropriate format and captured by the electronic

document management system. After verification that its contents have been captured, that

media may be destroyed according to but not limited to Reference (g) and NARA disposition

rules. This does not preclude copies of the same documentation being kept in other DoD or VA

approved record management systems; in such cases the copy in the DoD Health Record

document management system will be considered a part of the official DoD Health Record.

g. In accordance with Reference (u), medical departments will ensure an outpatient and

inpatient coding compliance plan is available at their facility. Service specific checklists exist to

review the entire record to ensure completeness and accuracy of diagnostic and procedure

information included in the DoD Health Records.

h. When Service members or beneficiaries relocate, closing out, printing, and transferring

records maintained in electronic systems is not necessary as long as authorized users in the

gaining facility have full access to those systems. This applies to the entire DoD Health Record.

i. Healthcare documentation created on paper or on electronic systems in the operational

medicine environment (shipboard and battlefield care) must be managed in accordance with

HIPAA and other applicable laws to the extent possible. Unless specifically excluded by other

provisions of this instruction, the information from the operational environment will be copied

into the systems that comprise the STR. Summary documents containing the essential

information may be created to meet this requirement.

j. When a beneficiary’s status changes, the relevant information in the existing DoD Health

Record will be incorporated into a new DoD Health Record as needed. Records personnel will

evaluate whether such a change may require a different record retention period in compliance

with existing NARA disposition schedules for the different categories but will not be shortened

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beyond the date any previous category required. Inclusion or exclusion of information in the

new DoD Health Record will be evaluated at that time. The medical records personnel will

follow Service-specific policy for noting changes in beneficiary status.

k. Before any permanent change of station reassignment, personal geographic location

move, MTF reassignment, or change to TRICARE enrollment location, medical records

personnel will take all steps necessary to ensure the gaining MTF has access to the beneficiary’s

complete STR, NSTR, or OHTR in digital format whenever possible.

l. If a Service member or beneficiary is moving or being assigned to a duty location that

does not have access to the current DoD EHR system, the losing medical department will

provide the beneficiary a paper or digital copy (whichever is the beneficiary’s preference) of all

historical patient encounter notes, and all laboratory and radiology results.

m. Upon discovery, LLF or orphaned medical documents must be labeled with adequate

patient identification information and integrated with the original DoD Health Record using the

electronic document management system as quickly as possible but no later than 30 days after

discovery. If a document management system is unavailable, the documents must be combined

with the appropriate DoD Health Record according to existing Service policy.

n. MTF medical records managers will implement procedures in accordance with Service

and DHA guidance to ensure STRs contain all documented medical, dental, and mental health

care, including care provided by non-DoD practitioners, healthcare documented in EHR

system(s) and electronic dental record system(s), and STR artifacts and images maintained in

other electronic document management systems that are made available to them.

o. Medical records managers will follow Service guidance for review and reporting of

deficiencies in the DoD Health Record.

p. When paper-based medical records are in use, local medical department records

management policy must include measures to:

(1) Establish a methodology to obtain beneficiary medical records upon arrival on station

or upon initial enrollment and to digitize them, when possible.

(2) Establish custody of the DoD Health Record upon the patient’s initial visit and

digitize at least the material necessary for continuity of care, when possible.

q. When electronic systems are unavailable, personnel will transition to temporary paper-

based documentation. This paper will be digitized within 3 business days after the electronic

systems become available, except operational medicine (battlefield) locations. Military Services

will develop procedures for digitization of paper documentation after a system outage either

through direct entry into the electronic system(s), or through capture and integration into the

electronic document management system, depending on the duration of the system outage. The

U.S. Coast Guard will develop timelines and procedures specific to the documentation system in

use in the facilities for which it has responsibility.

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r. Military Services will develop maintenance (downtime) procedures, for scheduled

(planned) or unscheduled (unplanned) non-functioning information systems in accordance with

this instruction and DoDI 6055.05 (Reference (ae)). Included within the procedures is the

process for verifying the integrity of information entered immediately before the downtime, and

immediately after the system is back up, and ensuring records are sent to the right location and

arrive there intact. The maintenance (downtime) procedures will be part of the Military

Services’ overall continuity of operations plan to preserve, maintain, and reconstitute operations

under adverse conditions, internal or external.

9. ACCESS TO DoD HEALTH RECORD AND PHI AND PII

a. Medical record management personnel must ensure that records are protected against loss,

unauthorized destruction, tampering, and unauthorized access or use. Health information that is

transmitted electronically must follow the requirements in References (u) and (ae) and DoDI

6055.01 (Reference (af)) and DoDI 6000.14 (Reference (ag)). Service-specific guidance assigns

the responsibility for the security of DoD Health Records to appropriate individuals. All

personnel having access to the DoD Health Record will protect the privacy of PHI and PII in

accordance with References (i), (k), and (r). MTF leaders with responsibilities for medical

record management must evaluate and implement administrative, technical, and physical

safeguards to reasonably protect health information from unauthorized use or disclosure, and to

limit instances of incidental disclosure in compliance with Service policy and all applicable rules

and regulations.

b. DoD Health Record documentation must be maintained in a secured area, room, or

appropriate secured, paper-file storage enclosure, and system to ensure safekeeping. In some

locations, it may be necessary to secure health record documentation with a 24-hour watch, when

possible (except operational medicine locations). MTFs will implement physical safeguards for

health information system components in accordance with Reference (s).

c. Access to all open record or electronic media storage areas must be restricted to

authorized personnel who require the paper data in the performance of their official duties.

Personnel granted access must be trained on HIPAA Privacy and Security and the requirements

in this instruction regarding safeguarding PHI maintained in the medical department. The

procedures and requirements in this instruction and References (r) and (s) will be used to expand

existing Service training materials for appropriate access to and handling of PHI and PII. MTF

commander approval or authorization is required for unescorted access to medical records areas.

d. DoD Health Records will be made available on a tiered schedule based on the need that

the record supports. The categories of availability are:

(1) Immediate availability, where the response time from inquiry is less than 3seconds.

Computable elements are necessary for clinical decision support (e.g., Problem List). This

includes all items necessary in accordance with the meaningful use criteria described in section

DoDI 6040.45, November 16, 2015

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201 of Title 42, U.S.C, also known as “The Health Information Technology for Economic and

Clinical Health Act” (Reference (ah)).

(2) Archival availability, with a response time from inquiry of 1 business day:

(a) Digital images and other working papers, if available, may be archival

documents.

(b) Archived records: When a patient is no longer eligible for care, that is, no longer

a beneficiary of the DoD, then the entire DoD Health Record may be archived.

e. A patient may request an account of disclosures of PHI and PII for the previous 6-year

period. Medical departments will account for disclosures in accordance with Reference (k).

f. Each MTF will establish a mechanism that tracks disclosures of PHI within the guidance

outlined in DHA- and Service-level policies as required by law. Military Services will use a

standardized tracking mechanism for accountable HIPAA disclosures at their MTFs. When

technically feasible, this disclosure tracking data must be centralized, and the tool used capable

of accounting for disclosures made throughout the MHS, conforming to all privacy and security

safeguards. The tracking mechanism will allow qualified individuals to generate and review a

report on disclosure activity in accordance with Reference (k).

g. Commanders of MTFs, senior-level Reserve Component medical authorities, and HIPAA

security officers (as established in accordance with Reference (s)) will determine by category of

personnel, derived from their job requirements, the appropriate role-based access to PHI.

(1) Appropriate implementation and compliance with the minimum necessary standard

in the HIPAA Privacy Rule requires that access controls be in place so that only information

needed to perform assigned job functions is accessed. Specific access permissions based on the

user’s role (role-based access) is the preferred method to accomplish this requirement.

(2) The HIPAA security officer will work with information managers to determine the

different roles needed and the information required for each role for effective job performance.

(3) System access is provided in accordance with Service-level guidance, and access is

contingent upon successful and timely completion of information assurance and other systems

compliance training. MHS standard training must be used when available.

h. Within MTFs and Reserve Component facilities, the following individuals may use the

information in DoD Health Records for treatment, payment, and health care operations purposes.

Access to substance abuse treatment records is limited in accordance with Reference (x).

(1) Medical personnel.

(2) Patient administration officers and associated personnel who need DoD Health

Record access to perform patient administration functions.

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(3) Other MHS personnel as determined necessary and documented by health care

facility commanders for treatment, payment, and health care operations purposes.

i. Information from the DoD Health Record may only be disclosed according to the

requirements in Service guidance and as permitted in accordance with References (d) through

(k), DoDI 1000.30 (Reference (ai)), and ASD(HA) Memorandum (Reference (aj)). Accounting

for disclosures must comply with the HIPAA Privacy Rule as established in Reference (k).

10. PATIENT IDENTITY MANAGEMENT

a. Military Services will develop procedures for establishing and maintaining a single,

unique DoD Health Record for each beneficiary based upon the Defense Eligibility and

Enrollment Record System (DEERS) identity.

b. DoD uses the DoD identification number (also known as electronic data interchange

person identifier (EDI-PI)) as the unique means for identifying individuals. This number is

cross-referenced against other unique identifiers collected, such as the Social Security Number

(SSN). Military Services will establish procedures to align the DoD Health Record with the

EDI-PI identification number and will comply with Reference (ai) regarding the reduction of the

use of SSNs at DoD.

c. The installation Military Personnel Section is responsible for validating a beneficiary’s

eligibility for DoD benefits. Designated MTF personnel perform a two-step check to confirm the

patient’s identity and verify entitlement:

(1) Complete a physical check of the Common Access Card or Uniformed Services

Identification card.

(2) Verify status in DEERS. Military Services will develop procedures for instances

where beneficiary status cannot be clearly determined to reduce the number of potential

duplicate DoD Health Records.

d. The Military Services will develop procedures for particular facility constraints to ensure

that newborns are clearly and uniquely identified in documentation to supplement the EDI-PI

when that is available. The sponsor SSN may be used in systems that do not yet support the

EDI-PI. Administrators must follow record system procedures to update a newborn’s personal

identification in their DoD Health Record as soon as the EDI-PI becomes available.

e. Military Services will develop policy and procedures directing the MTF records managers

to identify the appropriate category for episodes of care for dual- or multiple-eligibility patients

to the extent possible using the appropriate DoD Benefits Number. At a minimum, all entries

must be appropriately dated to facilitate resolution when an acceptable solution to account for

dual- or multiple-eligibility beneficiaries is developed.

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f. Military Services will develop procedures for establishing and maintaining a single,

unique DoD Health Record for non-beneficiaries – humanitarian patients and special designees

(e.g., allies, detainees, foreign national exchange/training participants).

11. DoD HEALTH RECORD DISPOSITION. Documentation that is part of the STR, NSTR,

or OHTR will be governed by the NARA disposition requirements for the specific component

record.

a. When an item of documentation is included in the DoD Health Record, the disposition of

the item is determined by the schedule pertaining to the component record of which it is a part,

and not the original disposition schedule for the stand-alone version of the original format of the

record item.

b. Documentation elements in the DoD Health Record that could belong to multiple

categories (STR, NSTR, OHTR) must be maintained according to the disposition requirement of

the most stringent (longest duration) component record.

c. Any electronic record system (including document management system) that has been

determined to comprise the record copy of the STR, NSTR, or OHTR must maintain that record

copy for the minimum period of time specified in the applicable disposition schedule. The

disposition schedules for the STR, NSTR and OHTR are:

(1) STR: Maintained in accordance with the current NARA disposition schedule

(Reference (o)).

(2) NSTR: Maintained in accordance with the current NARA disposition schedule

(Reference (p)).

(3) OHTR: Maintained in accordance with Reference (q). Components of the OHTR

must revert to the NSTR schedule.

d. A copy of the STR or NSTR, as appropriate, will be provided to DoD beneficiaries or

their authorized agent upon written request in accordance with DoDD 5400.07 (Reference (ak))

at any time prior to the end of the disposition period for that record.

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 GLOSSARY

GLOSSARY

PART I. ABBREVIATIONS AND ACRONYMS

AHLTA Armed Forces Health Longitudinal Technology Application

ASD(HA) Assistant Secretary of Defense for Health Affairs

ASD(M&RA) Assistant Secretary of Defense for Manpower and Reserve Affairs

CFR Code of Federal Regulations

DEERS Defense Eligibility and Enrollment Record System

DHA Defense Health Agency

DoDD DoD Directive

DoDI DoD Instruction

DoDMERB Department of Defense Medical Exam Review Board

EDI-PI electronic data interchange personal identifier

EHR electronic health record

EMR electronic medical record

HIPAA Health Insurance Portability and Accountability Act

IG DoD Inspector General of the Department of Defense

LLF late and loose-flowing (documents)

MHS Military Health System

MTF military treatment facility

NARA National Archives and Records Administration

NSTR non-Service treatment record

OHTR occupational health civilian employee treatment record

PHI protected health information

PII personally identifiable information

DoDI 6040.45, November 16, 2015

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SSN Social Security number

STR Service treatment record

U.S.C. United States Code

USD(P&R) Under Secretary of Defense for Personnel and Readiness

USMEPCOM United States Military Entrance Processing Command

VA Department of Veterans Affairs

PART II. DEFINITIONS

Unless otherwise noted, these terms and their definitions are for the purpose of this instruction.

AHLTA (noun). The 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.

archive (verb). To remove objects no longer in day-to-day use from the online system and place

them into long-term, retrievable storage.

archive (noun). According to context, the copy of a record that has been archived or the

collective DoD repository containing archived records. The archive is distinct from the “live”

electronic record system supporting ongoing care.

accession medical record. The foundation of the Service member’s longitudinal DoD Health

Record. It includes the medical examination performed by the USMEPCOM or DoDMERB

personnel, including associated internal and external records (paper or digital), as required.

advance directive. 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.

authorized personnel. Personnel who, through a verification process, have presented a legitimate

requirement to access medical records and been approved.

beneficiary. A person eligible to receive care in an MTF.

clear and legible reports. 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

DoDI 6040.45, November 16, 2015

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an MTF, or reports of any other such care provided without a referral, in accordance with

Reference (x).

DEERS. Defined in DoDI 1000.25 (Reference (al)).

digital signature. 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.

direct services. 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.

document management system. 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.

DoD Benefits Number. A unique identifier assigned to a beneficiary based on association with a

DoD sponsor and used to determine benefits. DoD beneficiaries who have multiple sponsors

will be assigned unique DBNs for each relationship.

DoD Health Record. 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.

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Change 1, 04/11/2017 GLOSSARY

DoD identification number. A unique 10-digit identifier assigned to each person who has a

record in the DEERS database, including all military personnel, family members, employees,

most contractors. The DoD identification number identifies the individual in all interactions with

DoD. Also known as the EDI-PI.

downtime. The time during which a functional machine or system is not functioning properly or

is otherwise unavailable to users.

draft record entry. 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.

EDI-PI. See DoD identification number.

eHealth exchange. 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, and millions of patients. The eHealth Exchange improves the health and welfare of

all Americans through health information exchange that is trusted, scalable, and enhances quality

of care and health outcomes by supporting comprehensive longitudinal health records.

healthcare operations. Healthcare related management activities performed in accordance with

References (i) and (k) and governed by the Privacy Rule defined in part 164 of Title 45, CFR

(Reference (am)).

HIPAA security officer. An official with statutory or operational authority and responsibility for

the development, implementation, maintenance, oversight, and reporting of security

requirements for electronic PHI in accordance with Reference (r) and parts 160, 162, and 164 of

Reference (am).

indirect services. Related to patient care but does not require interaction between the health care

provider and the patient. Examples include record reviews and record corrections.

inpatient. A patient who is admitted to a hospital or clinic for treatment that requires at least one

overnight stay.

inpatient record. The set of health care documentation recorded during a period of

hospitalization.

The Joint Commission. 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.

LLFs. 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

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 GLOSSARY

applied to documents pertaining to an STR and discovered in an MTF after the STR has been

archived or sent away.

MTF. A military facility established for the purpose of furnishing medical and dental care to

eligible individuals.

metadata tag. 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.

minimum necessary standard. When using or disclosing 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.

NSTR. 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 STR.

occupational health. 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.

OHTR. The occupational health record for all categories of DoD civil service workers, covered

contractors, or other groups provided occupational health services by the DoD.

outpatient. A patient who is not admitted into a hospital. Outpatient care includes care in

emergency rooms, same day surgery centers, and ambulatory procedure clinics for patients who

are not subsequently hospitalized overnight during the episode of care.

PII. Defined in Reference (h).

PHI. Defined in Reference (k).

patient identity. Defined in Reference (al).

psychotherapy notes. 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.

role-based access. 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.

sensitive information. Information determined by the MHS or an individual healthcare provider

to deserve special precautions to prevent inadvertent disclosure by or to medical record system

users.

DoDI 6040.45, November 16, 2015

Change 1, 04/11/2017 GLOSSARY

STR. The chronologic record of medical, dental, and mental health care received by Service

members during the course of their military career. It includes documentation of all outpatient

appointments (i.e. without overnight admittance to a hospital, clinic, or treatment facility), as

well as summaries of any inpatient care (Discharge Summaries) and care received while in a

military theater of operations. The STR is the official record used to support continuity of

clinical care and the administrative, business-related, and evidentiary needs of the DoD, the VA,

and the individual.

STR certification form (DD Form 2963). 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.

TRICARE. The DoD health care program that provides health care coverage for medical

services, medications, and dental care for military families, retirees and their families, and

survivors.

voice recognition. Computer analysis of the human voice, especially for the purposes of

interpreting words and phrases or identifying an individual voice.