Completing The Adult Preventive and Chronic Care Flow Sheet

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CompletingThe Adult Preventive and Chronic Care
Flow Sheet
Health Promotion Naval Hospital Camp Lejeune, NC

• DD Form 2766

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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 klancharl_at_nehc.med.nav
y.mil with further adaptation for implementation
at Camp Lejeune area medical facilities green
and blue side.
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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
• http//forms.daps.mil/order/
• Continuation Sheet DD2766C NSN 0102-LF-984-9600

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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

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1. Allergies Document medication and
environmental allergies.
2. Chronic Illnesses List any chronic illnesses.
NKDA
Zovirax 150mg 5xs daily Synthroid 75mcg
qd Flonase 1 squirt ea nostril qd
Herpes HypothyroidismHashimotos Allergic
rhinitis
3. Medications - list current non-Rx Will be
written in Pencil
This is the top of page 1 of DD Form 2766.
Pages 1 and 2 should be updated at every visit.
4. List Hospitalizations and Surgical procedures
to include date.
s/p appendectomy 1995
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On 10 Jan 00, this 28 y.o. woman and her provider
discussed the importance of weight-bearing
exercise (F), General Nutrition for Weight
reduction (N), and exercise injury prevention
(I). NOTE Entering the codes here does not take
the place of quality counseling documentation on
the SF 600!!
On St. Patricks Day, they discussed alcohol and
tobacco use. The provider really only needs to
enter the codes (A and To).
When an advance directive is filed in the chart
(in Section IV), enter the date here.
To document counseling, simply enter the date,
the patients age, and the codes for the topics
that were discussed.
First, always ensure that the patients
identifying information is entered.
This is the bottomof page 1-- where counseling
is documented.
20 June 2000
Female
AD
SGT
USMC
14 Jun 1973
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After youve entered a test result, determine
when that test should be performed again, then
fill in the corresponding circle. This will
serve as a reminder at future visits.
For any other test, you may enter a code for
the result...
This is the top of page 2 of DD Form 2766.
When any test is performed, enter the result in
the appropriate cell.
Enter the date the annual PHA was accomplished
Darken in the circle for the next scheduled PHA
The bottom of page 2 is the Screening Exam
section. Once you enter a calendar year and
age, go ahead and enter them across the whole
row.
BP should be checked next year.
...and the codes can be found here!
2000 28
3/7/02
142 66
132 / 86
Chol 122, TG 21 HDL 65, LDL 53
But lipids dont need to be checked for another 5
years.
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Notice that, if a test was ordered and the
results are pending, the entry should be in
pencil. The final result should be enteredin
penonce it is available.
Only X needed to be entered for the Pap result.
This provider opted to enter more information.
N
6/15/00 pending
6/15/00 X--ASCUS repeat 3 mo
This is the bottom of page 2a continuation of
the Screening Exam section.
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If member is in flight status complete this
section. Check appropriate box.
Pages 3 and 4 should only be included in the
medical records of active duty personnel.
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
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• 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

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Enter Blood Type results
29Jan02
A Pos
16Feb97
Enter date Blood Type was drawn
Date cleared by Medical for Physical Fitness
Assessment Navy Personnel Only
Section 10. Readiness. Completed at initial
PHA visit - transcribe information from previous
documentation in the medical record. 10e.1
Enter date, if on LIMDU or awaiting PEB. 10.e,
2 through 7 Disregard 10.f. Write optometry
Rx. Section 11. Deployment Enter the date and
location of any OCONUS deployments
For Navy Personnel ONLY (not Marine PFT) the PCM
is to enter the date the member was cleared for
participation in the Physical Fitness Assessment
- clearance is presumed to be good for 1 year,
unless medical conditions change. If waivers are
granted the granting date and expected
re-evaluation date are documented.
Enter date DNA was drawn
Enter dates of OCONUS deployment
Enter location of OCONUS deployment
18Jun97
14Jun98
26Jun99
Enter the dates annual HIV was accomplished
03Sep01
Pakistan
30Sep02 05Mar02
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And, finally, page 4. This page is simply a
continuation sheet, which can be used for
MTF-specific prevention items.
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Use DD Form 2766is now mandated byOPNAVINST
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)
• http//forms.daps.mil/order/