Health Assessment

Idaho
Department of
Correction

Standard
Operating
Procedure

Division of
Education
and
Treatment

Operational
Services
Control Number:
401.06.03.034
Version:
2.0
Page Number:
1 of 6
Adopted:
10-9-1998
Reviewed:
3-26-2009

Title:
Health Assessment

This document was approved by Dr. Mary Perrien, chief of the Division of
Education and Treatment, on 3/26/09 (signature on file).
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY STATEMENT NUMBER 401
Hospitalization, Institutional Clinical Services, and Treatment
POLICY DOCUMENT NUMBER 401
Hospitalization, Institutional Clinical Services, and Treatment
DEFINITIONS
Standardized Definitions List
Contract Medical Provider: A private company under contract with the Department to
provide comprehensive medical, dental, and/or mental health services to the incarcerated
offender population. A contract medical provider may include private prison companies and
other entities under contract with the Department to operate the Idaho Correctional Center
(ICC) and other out-of-state facilities housing Department offenders.
Facility Health Authority: The contract medical provider employee who is primarily
responsible for overseeing the delivery of medical services in an Idaho Department of
Correction (IDOC) facility.
Facility Medical Director: The highest ranking physician in an Idaho Department of
Correction (IDOC) facility.
Health Assessment: The process whereby an individual’s health status is evaluated,
including questioning the patient about symptoms.
Health Authority: The Department employee who is primarily responsible for overseeing or
managing the Department’s medical and mental health services. The health authority is
commonly referred to as the health services director.
Physical Examination: An objective, hands-on evaluation of an individual that involves the
inspection, palpation, auscultation, and percussion of a patient’s body to determine the
presence or absence of physical signs of disease.
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401.06.03.034
Version:
2.0
Title:
Health Assessment
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PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures for a
program to ensure (1) that offenders receive initial and periodic health assessments in a
timely manner, (2) periodic health assessments are conducted by appropriately qualified
healthcare professionals, and (3) significant periodic health assessment findings receive
timely interventions by appropriately qualified staff.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers and subcontractors.
RESPONSIBILITY
Health Authority
The health authority is responsible for:
• Monitoring and overseeing all aspects of healthcare services, and
• The implementation and continued practice of the provisions provided in this
SOP.
When healthcare services are privatized, he will also be responsible for:
• Reviewing and approving (prior to implementation) all applicable contract medical
provider policy, procedure, and forms; and
• Monitoring the contract medical provider’s performance, to include but not limited
to reviewing processes, procedures, forms, and protocols employed by the
contract medical provider to ensure compliance with all healthcare-related
requirements provided in respective contractual agreements, this SOP, and in
National Commission on Correctional Health Care (NCCHC) standards P-E-04,
Initial Health Assessment and P-E-12, Continuity of Care During Incarceration.
(See section 4 of this SOP.)
Note: Also see SOP 401.06.03.044, Continuity of Care during Incarceration.
Contract Medical Provider
When healthcare services are privatized, the contract medical provider is responsible
for:
• Implementing and practicing all provisions of this SOP, unless specifically
exempted by written contractual agreements;
• Ensuring that all aspects of this SOP and NCCHS standards P-E-04 and P-E-12
are addressed by applicable contract medical provider policy and procedure;
• Ensuring facility health authorities utilize all applicable contract medical provider
policy, procedure, forms, and educational information to fulfill all healthcare-
related requirements provided in this SOP, NCCHC standards P-E-04 and P-E-
12, or as indicated in their respective contractual agreement(s); and
• Ensuring all applicable contract medical provider policy, procedure, and forms
are submitted to the health authority for review and approval prior to
implementation.
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Version:
2.0
Title:
Health Assessment
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Note: Also see SOP 401.06.03.044, Continuity of Care during Incarceration.
Note: Nothing in this SOP shall be construed to relieve the contract medical provider(s)
of any obligation and/or responsibility stipulated in respective contractual agreements.
Facility Medical Director
The facility medical director and facility health authority (or designees) will be jointly
responsible for training staff and establishing contract medical provider procedures and
systems of control to ensure that healthcare services staff are appropriately trained to
perform the duties described in this SOP.
Facility Health Authority
The facility health authority will be responsible for:
• Ensuring the presence of an adequate number of appropriately trained staff and
materials are available to meet the requirements of this SOP, and
• Establishing and monitoring applicable contract medical provider policy and
procedure to ensure that all elements of this SOP and NCCHC standards P-E-04
and P-E-12 are accomplished as required.
Note: Also see SOP 401.06.03.044, Continuity of Care during Incarceration.
In addition, to the above responsibilities, the facility health authority and the facility
medical director (or designee) will be jointly responsible for training staff and establishing
contract medical provider procedures and systems of control to ensure that healthcare
services staff are appropriately trained to perform the duties described in this SOP.
Table of Contents
General Requirements ......................................................................................................... 3
1. Introduction .................................................................................................................... 3
2. Guidelines ...................................................................................................................... 4
Full Health Assessment ............................................................................................ 4
Modified Health Assessment .................................................................................... 5
Reassessments ........................................................................................................ 5
Conditions Requiring Special Interest ....................................................................... 5
3. Informing the Offender of the Results ............................................................................. 5
4. Compliance .................................................................................................................... 6
References ........................................................................................................................... 6
GENERAL REQUIREMENTS
1. Introduction
The assessment of an individual offender’s health status provides the initial baseline for
healthcare to be recommended during incarceration. The health assessment provides
essential information for (1) the diagnosis of health conditions that are preventable or
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treatable, (2) the continuity of care for chronic health conditions, (3) classifying healthcare
(i.e., determining the frequency and content of follow-up health status assessments during
the offender’s incarceration), and (4) classifying the offender (i.e., determining which
institution to house the offender, and determining the offender’s work and activity
assignments or restrictions).
2. Guidelines
Health assessments will be done as indicated.
• The physical examination portion of the health assessment shall be performed by a
physician, physician assistant, or nurse practitioner.
• The data collected and reviewed during the health assessment shall be recorded in
the offender's healthcare record at the time the assessment occurs.
• Housing, work, activity, or other restrictions necessary due to the offender’s health
condition shall be communicated to security staff via the forms and protocols
described in IDOC-approved contract medical provider policy and procedure.
• Within 24 hours of completing the health assessment, pertinent medical information
will be entered in the IDOC’s current electronic medical data management system
(e.g., Reflections or the Corrections Integrated System [CIS]). Check with the
health authority (or designee) for the appropriate system.
• Orders for further diagnostic evaluation, referral, and/or treatment of a health
condition shall be prescribed on the appropriate order sheet, with justifying
information documented in the progress notes.
Full Health Assessment
Newly committed offenders and offenders who have not been incarcerated in the
previous 90 days at an IDOC-operated facility--will receive a full health assessment
as soon as possible but no later than seven (7) days of admission. The full health
assessment will include, but will not be limited to:
• A review and collection of additional information to amplify any positive findings
noted during receiving screening;
• The collection and review of laboratory and diagnostic tests to detect
communicable disease, particularly tuberculosis and other communicable
diseases as determined in consultation with the State of Idaho’s Central District
Health Department (i.e., Idaho Health District 4);
• The recording and review of height, weight, pulse, blood pressure, and
temperature;
• A physical examination including,
♦ for women, a pelvic examination which includes a Papanicolaou (pap) smear,
gonorrhea culture, and Chlamydia and
♦ for men over 50, a prostate exam;
• A mental health screening;
• A dental screening;
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• A review of healthcare records information received from any correctional facility
having custody of the offender immediately prior to incarceration at an IDOC
facility;
• A review of prior significant findings and problems identified by a community
practitioner (if available); and
• The initiation of therapy and immunizations when appropriate.
Modified Health Assessment
Offenders re-entering an IDOC facility within ninety (90) days of release from an
IDOC-operated facility--will receive a modified health assessment. The modified health
assessment will include, but will not be limited to:
• A review of the healthcare record;
• A review of receiving screening results;
• A collection and review of laboratory and diagnostic tests to detect
communicable disease;
• The recording and review of height, weight, pulse, blood pressure, and
temperature; and
• A review of healthcare records information received from any correctional facility
having custody of the offender immediately prior to incarceration at an IDOC-
operated facility.
Reassessments
Offenders Under 40
Any offender under 40 years of age shall be offered the opportunity of reassessment
every five (5) years.
Offenders 40 to 50
Any offender 40 to 50 years of age shall be offered the opportunity of reassessment
(inclusive of mammograms) every two (2) years.
Offenders 50 and Over
Any offender 50 years of age or over shall be offered the opportunity of reassessment
(inclusive of mammograms and prostate exams) on a yearly basis.
Conditions Requiring Special Interest
If an offender's health condition requires special interest, the health assessment may be
more frequent as warranted.
3. Informing the Offender of the Results
The offender shall be informed within two (2) weeks of the results of the health assessment
and provided recommendations for further evaluation, referral, testing or treatment, if any.
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4. Compliance
Compliance with this SOP and all related Department-approved protocols will be monitored
by the health authority (or designee) by using various sources to include: this SOP, clinical
practice guidelines, routine reports, program reviews, and record reviews.
The health authority (or designee) must conduct two (2) audits a year (or more frequently as
desired based on prior audit results). The audits must consist of monitoring applicable
contract medical provider and IDOC policy and procedures, applicable NCCHC standards,
and the review of a minimum of 15 individual records.
REFERENCES
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-E-04, Initial Health Assessment
National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-E-12, Continuity of Care during Incarceration
– End of Document –