Documentation of casualty care is ultimately the responsibility of the LC providing direct care. All theater and local command documentation requirements should be completed by the LC. Best practice, however, is for REs to also document their consultation and recommendations and to send them to the LC as soon as possible. For routine consultations, this is automatic within the GTP. For TC not utilizing the GTP (urgent/emergent consultation), asynchronous communication between LCs and REs is on an ad hoc basis (using HIPAA compliant messaging applications or using encrypted email).

Additionally, REs document all OVH encounters using the Operational Virtual Health Report (OVHR) available at: https://info.health.mil/army/VMC/Lists/OperationalVirtualHealthReport/Item/newifs.aspx?source=/army/VMC/Pages/VMC/ADVISOR.aspx (must have CAC enabled computer/mobile device).

If a TC is for a casualty who is a Military Health System beneficiary, and at least two of the following patient identifiers are available and can be provided by the LC managing the casualty, REs should document the encounter in MHS Genesis or other electronic medical record:

- Patient name
- Social Security Number
- DoD Identification Number
- Date of Birth

Best practice is to copy information from the OVHR into the appropriate note in the EMR.

TC encounters for patients who are NOT MHS beneficiaries or for whom identifiers are not available/cannot be provided cannot have documentation in the EMR. REs will complete OVHRs and send recommendations to LCs as described above.

LCs utilizing ADVISOR for TC are also asked to complete an Operational Virtual Health Evaluation (OVHE) available at: https://info.health.mil/army/VMC/Lists/OperationalVirtualHealthEvaluation/Item/newifs.aspx?source=/army/VMC/Pages/VMC/ADVISOR.aspx .

When deployed LCs need to follow up with the appropriate medical theatre POCs on where they should document the patient encounter.