D. Post-Gulf War Policy

Since the Gulf War, military medical recordkeeping broadly reflects an on-the-horizon focus on the deployable medical record and an over-the-horizon orientation toward the computer-based patient record. Routine recordkeeping policy continues to be made principally by the three services. However, to a greater extent than before the Gulf War, DoD (Health Affairs), the Joint Staff, and the combatant commands are playing active roles, especially in deployment-related recordkeeping. Expectations of the recordkeeping component of force health protection remain high as military personnel continue to be deployed overseas in support of operational missions. DoD policies are also moving slowly toward some degree of standardization in basic medical recordkeeping among the services. The Army and Air Force have continued their policy of deploying personnel with an abstract of the individual health record rather than the record itself. The Navy and the Marine Corps have continued their policy of deployment with full health records.

The three military Surgeons General continue to establish service-specific policy on the content and management of medical records. Each service has published revised medical recordkeeping policy since the end of the Gulf War.[64] The services have likewise updated their policies on the disposition of records, each having published distinct directives covering the disposition of all types of military documents as well as medical records.[65] DoD (Health Affairs) has focused on the development of electronic systems and automated devices, like the computer-based patient record (CPR) and the personal information carrier (PIC), and on the documentation of deployment-driven medical surveillance activities. (The terms "computer-based patient record," "computerized medical record," and "electronic medical record" are often used interchangeably. The terms "personal information carrier," "portable information carrier," and "medical personnel information carrier" are also used interchangeably.)

Joint Staff doctrine also influences medical recordkeeping policy. Joint Publication 4-02, Doctrine for Health Services Support in Joint Operations, is in the process of being rewritten following a DoD-wide reassessment in 1997.[66] The current (1995) publication refers to minimizing the number of medical records and reports, and recognizes that records and reports can serve operational information requirements without modification or supplementation.[67] A 1998 draft of the revised Joint Publication 4-02 contains extensive new commentary on force health protection, while continuing with the current guidance on medical recordkeeping.[68] The Joint Staff is also engaged in a project that would lead to a uniform records management policy during deployments and a consistent records disposition schedule across the unified commands.[69] This initiative (to be completed in 1999) is in response to recommendations contained in a report by the Senate Committee on Veterans Affairs about the retention of "…all records, logs, and other documents related to wartime and other military operations…."[70]

Importantly for veterans, there is progressive cooperation among the Department of Defense, the Department of Veterans Affairs, and the National Archives and Records Administration on developing standardized policies for the transfer and storage of medical records.

Given the far-reaching concerns surrounding post-conflict illnesses among Gulf War veterans, it is perhaps not surprising that the Congress has provided legislative direction regarding military medical recordkeeping. The National Defense Authorization Act for Fiscal Year 1998 contained the following language in reference to an improved medical tracking system for servicemembers deployed overseas in contingency or combat operations:

The results of all medical examinations conducted under the system, records of all health care services (including immunizations) received by members described in sub-section (a) in anticipation of their deployment or during the course of their deployment, and records of events occurring in the deployment area that may affect the health of such members shall be retained and maintained in a centralized location to improve future access to the records.[71]

Content of the record: Post-Gulf War policies on the content and format of medical records are comprehensive and generally consistent, but they are not standardized. Each service continues to use different forms to describe a patient’s physical status,[72] as well as to document an episode of inpatient  care, to summarize major health conditions, and (until recently) to serve as a deployed medical record.[73] All three services have continued their stated policies on cross-servicing (maintaining) each other’s medical records.[74]   The terms used to describe military medical records have also changed somewhat, but are not yet standardized (Table 2).

Table 2. Post-Gulf War medical record terminology


INDIVIDUAL HEALTH RECORD (outpatient record)



Health Record (HREC)

Inpatient Treatment Record (ITR)


Health Record (HREC)

Inpatient Record (IREC)

Air Force

Outpatient Record

Inpatient Record

The issue of deployment is addressed in varying degrees in the services’ principal medical recordkeeping policy directives. The Army provides fairly extensive guidance in both the regulation on medical record administration and the field manual on medical company tactics, techniques, and procedures. Key points include the continued prohibition on individual health records accompanying soldiers deployed to combat areas and the merger of field medical files with individual health records after demobilization. The Army’s guidance also refers to the future fielding of "…an electronic device (automated individually carried record system) that stores medical or dental, personnel, and finance data" during deployments.[75]

The Navy likewise provides quite detailed guidance on the maintenance of medical records by deployable units or under combat conditions. (Unlike in the Army or the Air Force, full individual health records accompany Navy and Marine Corps personnel in an operational environment. Although not specified in written policy, staff from the Navy’s Bureau of Medicine and Surgery advised that the reasons for deploying with full records are 1) Navy personnel are (permanently) assigned to ships as "ship’s company," and 2) Marine Corps deployments are configured so that battalion aid stations can accommodate maintenance of the full individual health records.[76]) The Navy’s guidance also specifically emphasizes the value of proper (operational) medical recordkeeping to both the government and the servicemember in establishing entitlement to benefits for a service-connected disability.[77]

The Air Force’s medical recordkeeping directive concisely addresses the generation, maintenance, and disposition of inpatient records at tactical medical facilities.[78] Air Force deployment planning guidance calls for the Summary of Care form (AF 1480), later replaced by the Adult Preventive and Chronic Care Flowsheet (AF 1480A/DD 2766), to accompany all deploying personnel.[79] This is a continuation of the change from the Air Force’s pre-Gulf War policy of sending the individual health record for any deployment lasting 30 days or longer.[80]

Deployment-related medical recordkeeping policy is also being driven by two DoD publications concerning joint medical surveillance in support of military operations: Joint Medical Surveillance (DODD 6490.2) and Implementation and Application of Joint Medical Surveillance for Deployments (DODI 6490.3). The latter publication is particularly instructive, addressing such topics as the maintenance of "personal medical readiness records," the inclusion of pre- and post-deployment health screening assessments in individual medical records, the documentation of medical and health-related events during deployment, and the development of automated recording devices and electronic medical records. Reference is also made to a geographical information system that would be used for "spatial analyses" of environmental and disease exposures, and that would be capable of being linked to individual medical records.[81]

In October 1998, DoD (Health Affairs) issued a policy memorandum that introduced standardized pre- and post-deployment health assessments, as required by the DoD Instruction 6490.3. The new health assessments (which do not yet have form numbers assigned) contain eight pre-deployment questions and six post-deployment questions. The original assessment forms will be placed in the individual health record, and copies will be mailed to the DoD Deployment Surveillance Team office in Falls Church, Virginia. The objectives of the assessments continue to be quick confirmation and documentation of a servicemember’s health readiness for deployment or redeployment, and a determination of whether there is a need for a clinician’s evaluation before deployment or redeployment.[82]

In December 1998, the Joint Staff issued a policy memorandum that provided routine, standardized procedures for conducting health surveillance and assessing health readiness in conjunction with deployments. Key points include a thorough review and updating of the individual health record prior to a deployment, documentation of every patient encounter and each "reportable medical event" during a deployment, and appropriate archiving of all deployment-related medical records and health documents. This Joint Staff policy, effective February 1, 1999, further implements the August 1997 DoD directive and instruction and the October 1998 DoD (Health Affairs) memorandum on deployment health surveillance.[83] Previously, medical recordkeeping policy from the unified combatant commands focused primarily on the documentation of medical surveillance activities. For example, initial deployment preventive medicine guidance from the US Central Command (CENTCOM) made minimal reference to medical recordkeeping.[84] More recent CENTCOM policy required the preparation of a deployed medical record and directed that copies of the pre- and post-deployment questionnaires be filed in the medical record.[85] Policy from the US European Command (EUCOM) for Operation Joint Endeavor (OJE) in Bosnia directed that redeployment medical screening would be documented on a special form (OJE-Redeployment-SF 600) and maintained in the individual health record.[86]

The current (1994, but being revised) joint directive establishing the Armed Forces Immunization Program, along with service-specific medical recordkeeping directives, reflects the services’ different policies for documenting immunizations in medical records. According to these directives, immunizations for Army, Navy, and Marine Corps personnel continue to be recorded on both the Immunization Record (SF 601) in the individual health record and the International Certificates of Vaccination (PHS 731). Air Force immunizations are recorded on the Adult Preventive and Chronic Care Flowsheet (AF 1480A) in the member’s health record as well as on the PHS 731.[87]

These policies on the documentation of immunizations and the use of abbreviated health records for deployments have been affected by the 1998 issuance of an Adult Preventive and Chronic Care Flowsheet (DD 2766). This four-part DoD form is virtually identical to the Air Force form 1480A of the same title issued in 1997. The DD 2766 is being implemented by the Navy in response to the DoD (Health Affairs) March 1998 policy memorandum on Put Prevention Into Practice (PPIP). PPIP is part of a national campaign developed by the Department of Health and Human Services, which focuses on health promotion and wellness activities. The Navy will document immunizations in the individual health record using the DD 2766 instead of the SF 601.[88]

In addition to PPIP-focused policy, the Army and the Air Force are employing the DD 2766 in the broader context of deployment medical surveillance. The Army published guidance in March 1999 that directed replacing the SF 601 and the DA 8007 with the DD 2766 for documenting clinical preventive services and immunizations. The DD 2766 will also serve as the medical treatment folder (record) for Army personnel during deployments.[89] The Air Force published deployment medical surveillance guidance in August 1998, specifying the new DD 2766 as a replacement for the AF 1480A deployable medical record.[90] Additional Air Force guidance on using the DD 2766 for documenting medical care during deployments was published in February 1999.[91]

The documentation of investigational drugs and vaccines remains a difficult issue. In its 1997 request for comments on the rule that waived the requirements for informed consent from personnel who took investigational products during the Gulf War, the Food and Drug Administration (FDA) recognized that the rule did not work as anticipated, and specifically mentioned problems with recordkeeping. As part of its request for comments, the FDA cited a recommendation from the Presidential Advisory Committee on Gulf War Veterans’ Illnesses that the adequacy of recordkeeping (for investigational products) be re-visited if the FDA decided to reissue the interim rule as final. The FDA requested specific comments on whether and how recordkeeping should be addressed in the rule.[92] In its comments on the rule, the DoD felt that existing FDA regulations on recordkeeping were adequate and noted ongoing initiatives to develop automated recordkeeping and immunization tracking systems.[93] A 1998 report by the National Science and Technology Council also cited the need for improved systems to capture and transfer information regarding investigational drugs.[94]

Likewise, challenges continue to be associated with the documentation of drugs distributed widely to servicemembers under the conditions described earlier. The DoD’s goal is that servicemembers be fully informed about all medical countermeasures, and that such countermeasures, when used, are documented and maintained as part of the individual’s health record.[95] In March 1998, DoD (Health Affairs) issued policy on the distribution and disposition of ciprofloxacin (or the alternative doxycycline), indicating that the commander in chief of the combatant command is responsible for ensuring accurate and thorough documentation of the distribution and disposition of the antibiotic. Either medical staff or line staff may issue this drug. In either case, detailed information must be recorded in a log when this drug is issued as well as when unused drugs are collected on re-deployment. Copies of the logs are to be forwarded to the US Army Center for Health Promotion and Preventive Medicine. If this drug is issued through medical channels, the appropriate information is to be entered in the service medical record.[96]

Consolidation of the record: The consolidation of medical information is especially important during and following deployment, when the documentation of outpatient and inpatient care received in a deployed medical treatment facility should be incorporated into the individual health record. Each service continues to require that, in most instances, some documentation of inpatient care (for example, copies of the summary or surgical report) be placed in the individual health record.[97]

The services’ medical recordkeeping policies vary in their treatment of logs and rosters. The Army refers to them as "paramedical" documents and notes that they "…are not considered medical records although they are kept in the same file with other medical records." [98] The Navy notes that the grouped administrative information contained in these documents is summarized in the patient’s medical record.[99] The Air Force broadly mentions rosters without specific guidance on their relationship to medical records.[100]

Policies regarding the management of stray medical documents are consistent in their direction to either locate the military member’s permanent health record or forward the documents to a headquarters component or personnel locator.[101] Typically, however, these policies are more suitable for fixed medical facilities and peacetime health services than for deployed medical treatment facilities in operational and post-deployment environments. The latter conditions can make it difficult to consolidate loose documentation, locate a member’s individual health record, and ultimately incorporate the documents into the permanent health record.

Custody of the record: Given the experiences from the Gulf War and the continuing operational deployments, custody considerations will remain important issues throughout the foreseeable future. While the policies of the military services continue to state clearly that medical records are the property of the US Government,[102] each service has quite specific and generally consistent guidance to allow access to medical records and release of medical information.[103] The current DoD policy specifies that patients have the right to review and copy their medical records.[104] As a general rule, the military services’ policies state that the individual health record will accompany a military member when admitted for treatment at a military medical facility, while copies of pertinent information from the health record may accompany the patient upon admission to a non-military facility.[105]

Policies on the transfer and storage of military medical records vary somewhat across the services. Following the Gulf War, the services continued to forward the individual health records of released, retired, or discharged servicemembers (who no longer have any form of service obligation) to the National Personnel Records Center (NPRC) in St. Louis.[106] However, since 1992 (for the Army) and 1994 (for the Navy, the Air Force, and the Marine Corps), individual health records of former servicemembers have been sent directly to the Department of Veterans Affairs Records Management Center (VA-RMC), also in St. Louis (Table 3). Records of members filing VA compensation claims are sent to the servicing VA regional office, and records of members joining the reserves or the guard are sent to the respective units.[107] This change in policy was intended to enhance the DoD’s and the VA’s responsiveness in serving military personnel and veterans.[108] It was driven by congressional interest in resolving concerns over excessive delays in processing medically-related benefits requests from former servicemembers.[109]

Table 3. Individual health record transfer to
Department of Veterans Affairs-Records Management Center




October 16, 1992


January 31, 1994

Air Force

May 1, 1994

Marine Corps

May 1, 1994

Another example of cooperation between the DoD and the VA which should improve service to veterans is the recent policy that separating or retiring military members should undergo only one comprehensive physical examination that meets both DoD and VA purposes regarding discharge medical condition and rating disability compensation. Previously, physical examinations performed by the military would not always be sufficient for service-connected disability determinations, often necessitating a second examination by VA physicians.[110]

For military inpatient transfers, the Army directs that the original inpatient record be sent when a patient is transferred to another Army medical facility, and that a copy of the inpatient record be sent when the transfer is to a Navy, Air Force, or VA medical facility.[111] The Navy and the Air Force direct that a copy of the inpatient hospital record be sent to the receiving medical facility. The Air Force allows an original inpatient record to be sent to another military medical facility if a copy cannot be made in time for the patient’s transfer.[112]

Inpatient records are retired differently than individual health records. Unlike individual health records, which move with servicemembers upon reassignment, inpatient records remain with the medical facility at which the hospitalization occurred. (Summaries of such hospitalizations are generally included in individual health records.) Inpatient records may be used for review by inspection and accreditation organizations to assess quality of care, as well as for medical education and research. After varying periods of time, inpatient records are retired in annual collections to the NPRC. They are retained by most Army and Air Force hospitals for one year, and by most Navy hospitals for two years, after the calendar year in which the hospitalization occurred. For military medical facilities with major research and education programs, inpatient records can be retained from three to five years before retirement to the NPRC.[113]

Persian Gulf veterans raised concerns to members of Congress in 1994 over missing portions of medical records, prompting the Assistant Secretary of Defense for Health Affairs to ask the military departments to describe "…the actual process for combining the field outpatient encounter with the permanent medical record of the servicemember with particular emphasis on the Persian Gulf Theater of Operations during Operations Desert Shield/Storm…" as well as "… the mechanism by which your Medical Department handles inpatient dispositions from the operational environment."[114] Army and Air Force responses essentially reiterated their current policies. These included generation of an abstracted medical history form rather than deploying the full individual health record, incorporation of the loose documentation generated during a deployment into the health record after demobilization, and forwarding of the deployment inpatient records (in separate collections) to the NPRC.[115] A copy of the Navy’s response could not be located.

In conjunction with the buildup of US military forces in Southwest Asia in early 1998, the Army issued a message on recordkeeping policy for the anticipated contingency operations. It provided guidance for the maintenance and forwarding of both operational and medical records, including clinic logs, command health reports, inpatient hospital records, and outpatient health records. The message directed that military inpatient records should be forwarded monthly to the NPRC. Records documenting outpatient care would be maintained in field file folders, which would subsequently be integrated with soldiers’ (permanent, non-deployed) health records through coordination between medical and support unit commanders.[116]

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