Completing The Adult Preventive and Chronic Care Flow Sheet by jasonpeters


									         Health Promotion
          Naval Hospital
        Camp Lejeune, NC

The Adult Preventive and Chronic
       Care Flow Sheet
          DD Form 2766
    In order to understand this
  presentation it must be viewed
      in “Slide Show” format.

Thank you to Maj Robin M. Janke, Air Force Population Health
Support Office for the original development of this presentation.

Adapted for Navy by Navy Environmental Health Center
PPIP Program Manager. Contact:
with further adaptation for implementation at Camp Lejeune area
medical facilities green and blue side.
              DD Form 2766
• A Tri-service form

• Used for all DoD military personnel and TRICARE
  Prime beneficiaries (adult only)

• Obtained from Navy Supply NSN 0102-LF-984-8400
• Continuation Sheet DD2766C
  NSN 0102-LF-984-9600
                 DD Form 2766
• Replaced NAVMED 6150/20 (Summary of Care)
   in 1998 (for adults)
• OPNAVINST 6120.3
  – provides guidance on implementation of PHA (Preventive
    Health Assessment)
• Documentation
  –   face-to-face encounter
  –   not solely a record review
  –   all levels of providers use it
  –   not only privileged providers
                                    1. Allergies
                              Document medication and
                              environmental 2. Chronic
Herpes                                    List any 5x’s daily
                                     Zovirax 150mgchronic
Hypothyroidism—Hashimoto’s           Synthroid 75mcg qd
                                     Flonase 1 squirt ea nostril qd
Allergic rhinitis

            3. Medications - list
             current & non-Rx
             Will be written in
                                    4. List This is the top of
                                            Hospitalizations and
                                       page 1 procedures to
                                       Surgical of DD Form 2766.
s/p appendectomy 1995
                                            include date.
                                       Pages 1 and 2 should be
                                        updated at every visit.
                         1/10/00    3/17/00
                            28       28
                          F, N, I   A, To

         On St. Patrick’s Day, woman and her
     On 10 Jan 00, this 28 y.o.they discussed
        alcohol and tobacco use. The provider
       provider an advancethe importance of
         When discussed directive iscodes (A
        really only needs to enter the
       weight-bearing exercise (F), General
          filed in the chart (in Section
                          and reduction
     Nutrition for Weight To).here. (N), and
            IV), enter counseling,
             document the prevention (I).
        Toexercise injury date simply
       enter the date, the patient’s age,
       NOTE: Entering the codes here does
       and the codes for the topics that
      not take the place of quality counseling
  First, alwaysJune 2000discussed. SF 600!!
              20 were
           documentation on the
ensure that This is the bottomof page 1--
    patient’swhere counseling is documented.
                             Jones       Mary                   Female
 information is                             AD               SGT

    entered.                                                  USMC
                                            20/123-45-6789 14 Jun 1973
           After you’ve entered a test result,
                                           be performed Dx’d at
determine when that test shouldDx’d at 48; F—colon caagain, 68
                           M—breast ca

                          For anyMI performed,
                             test other
          then fill in the M—HTN, is at 53 test,
            the When anycorresponding circle.
 enteringThis is the top of
           will serve asyou inEnterdiabetes
                             reminder the code
     Thisenter the result may enter a date visits.
                          aMGM—typethat future cell.
     family 2 of family history 2 appropriate
      Enter any DD Form 2766. at
       page                  for the result...
                                    the annual Darken in the
                           S—major depression PHA
  history, use
        is pertinent. For example,
       the                       was accomplished
     since the age when her mother circle for the
  relationshipmyocardial infarction next scheduled
      had her                                     BP should be
The bottom of page 2 is the Screening Exam section.
                                              2002 the codes
                                       2001 ...andactual
 abbreviations enter a28
       (MI) isyou
        Once                  enter 29 Thechecked 2004
                important, calendar year andPHA next 2005
                                        the 30       2003
                                                      age, 32
                                                      31        33
                                               can be found
                                             result must be
    that are and enter them across the whole row.
    go ahead                                          year.
   defined on              3/7/02                  here!
                                             entered for:

 the form (M,                66”

                           132 / 86
   F, S, etc.).
                         Chol 122, TG 21
                         HDL 65, LDL 53

                       But lipids don’t need to be
                     checked for another 5 years.
                               Notice that, if a
                              test was ordered
                   N            and the results
                pending        are pending, to
                           Only “X” needed the
                           be entered for the
                                entry should be
                3 mo             result. The
                             Papin pencil.This
                            provider opted to
                                  final result
                                enter more
                                   should be
                              entered—in pen—
     This is the bottom of         once it is
    page 2—a continuation          available.
of the Screening Exam section.
                                    If member is in
                                      flight status
                                      complete this
                  Pages 3 and 4      section. Check
      should only be included in the medical
        records of active duty

Section 8. Occupational History: Occ monitoring
programs, e.g. hearing conservation, rad, asbestos.

Section 9. Immunizations: Disregard this section.
 Use SF 601, place all copies after the DD 2766
  BMEDNOTE 6150 - although technically
expired, is still accurate and used as reference in
                OPNAVINST 6120.3
BUMEDNOTE 6150 gives guidance on proper
      completion of the DD 2766

   SF 601 still used instead of the DD 2766
           Immunization section
29Jan02              16Feb97   A Pos                   Enter
                                       Enter date Blood Type
                                       Blood Date cleared
                       Section ONLY (not Marine PFT)
           For Navy Personnel 10. Readiness:.
                                       by Medical
                               was drawn
    Enter date at initial PHAthe date transcribe information
           the PCM is to enter visit - the member was
                                      for the medical
     DNA was18Jun97 for participation in Physical record.
       from previous documentation in the Physical
           Fitness Assessment on 26Jun99 Fitness
                                    LIMDU or awaiting PEB.
         10e.1 Enter date, if - clearance is presumed to
      drawn 03Sep01 10.e,Enter datesDisregard
           be good for 1 2 through 7: Enter
                                          Enter the
                           year, unless medical conditions
                     If waiversof granted the granting
            change. 10.f. Write optometry Rx.
              date Deployment: Enter thedates are
                                    Navy Personnel
                            OCONUS OCONUS     date
       Section 11. and expected re-evaluation dateand location
                              documented. annual
                          deployment Only
                   of any OCONUS deployments
          Pakistan                              HIV was
         And, finally, page 4.
This page is simply a continuation sheet,
 which can be used for MTF-specific
            prevention items.
      Use DD Form 2766
     is now mandated by
     OPNAVINST 6120.3
DD Form 2766 (NSN 0102-LF-984-8400)
      available in packages of 100
 DD 2766C (NSN 0102-LF-984-9600)
      available in packages of 50
  from Navy Supply (stocking system)

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