Health Record

Idaho
Department of
Correction

Standard
Operating
Procedure

Operations
Division

Operational
Services
Control Number:
401.06.03.060
Version:
2.2
Page Number:
1 of 6
Adopted:
3-1-2001
Reviewed:
5-30-2012

Title:
Health Record

This document was approved by Shane Evans, director of the Education,
Treatment, and Reentry Bureau, on 5/30/12 (signature on file).
Open to the general public: Yes
BOARD OF CORRECTION IDAPA RULE NUMBER 401
Medical Care
POLICY CONTROL NUMBER 401
Clinical Services and Treatment
DEFINITIONS
Standardized Terms and Definitions List
Contract Medical Provider: A private company or other entity that is under contract with
the Idaho Department of Correction (IDOC) to provide comprehensive medical, dental,
and/or mental health services to the IDOC’s incarcerated offender population.
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 Authority: The Idaho Department of Correction (IDOC) employee who is primarily
responsible for overseeing or managing the IDOC’s medical services. (The health authority
is commonly referred to as the health services director.)
PURPOSE
The purpose of this standard operating procedure (SOP) is to establish procedures to
ensure that each offender has an integrated, problem-oriented healthcare record, which
includes medical, dental, and mental health data initiated upon admission and maintained
throughout the period of incarceration.
SCOPE
This SOP applies to all Idaho Department of Correction (IDOC) healthcare services staff,
offenders, contract medical providers and subcontractors.
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401.06.03.060
Version:
2.2
Title:
Health Record
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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, the health authority 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) standard P-H-01,
Health Record Format and Contents. (See section 5 of this SOP.)
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 NCCHC standard P-H-01 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 standard P-H-01, 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.
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 ensuring the presence of an adequate number of appropriately trained
staff and materials are available to meet the requirements of this SOP.
Facility Health Authority
The facility health authority will be responsible for establishing and monitoring applicable
contract medical provider policy and procedure to ensure that all elements of this SOP
and NCCHC standard P-H-01 are accomplished as required.
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401.06.03.060
Version:
2.2
Title:
Health Record
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In addition, to the above responsibilities, the facility health authority and the facility
medical director (or designee) will be jointly responsible for ensuring the presence of an
adequate number of appropriately trained staff and materials are available to meet the
requirements of this SOP;
Table of Contents
General Requirements ......................................................................................................... 3
1. Introduction .................................................................................................................... 3
2. Elements of the Healthcare Record ................................................................................ 3
3. Documentation Requirements ........................................................................................ 4
Infirmary ................................................................................................................... 4
Non-infirmary ............................................................................................................ 4
4. Record Management ...................................................................................................... 4
Storing ...................................................................................................................... 4
Transferring .............................................................................................................. 5
Reactivating .............................................................................................................. 5
Thinning .................................................................................................................... 5
5. Compliance .................................................................................................................... 5
References ........................................................................................................................... 5
GENERAL REQUIREMENTS
1. Introduction
The healthcare record is the primary tool used by healthcare services staff to manage the
assessment, treatment, and care of patients. The IDOC uses the problem-oriented structure
to organize the healthcare record. Standardizing the healthcare record enhances the quality
of healthcare services, promotes continuity of patient care and treatment, and ensures
consistent and accurate records throughout the IDOC.
2. Elements of the Healthcare Record
At a minimum, the healthcare record shall contain the following elements:
• Identification information (e.g., inmate name, IDOC identification number, date of
birth, and sex);
• A problem list containing medical and mental health diagnoses and treatments as
well as known allergies;
• Intake and transfer screening forms;
• Health assessment forms;
• Progress notes of all significant findings, diagnoses, treatments, and dispositions;
• Provider orders for prescribed medication and medication administration records;
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• Reports of laboratory, x-ray, and diagnostic studies;
• Flow sheets;
• Consent and refusal forms;
• Release of information forms;
• Results of specialty consultations and off-site referrals;
• Discharge summaries of hospitalizations and other in-patient stays;
• Special needs treatment plan, if applicable;
• Place, date, and time of each clinical encounter; and
• Printed name, title, and original signature of each documenter.
Note: Any and all changes made to the format and structure of the healthcare record,
including the implementation of an electronic medical record (EMR), must be approved in
writing in advance of the change being implemented. Such requests must be made in writing
to the health authority.
3. Documentation Requirements
• Each health encounter shall be documented by a healthcare professional.
• Except for healthcare records that are generated by community providers or other
correctional agencies, only IDOC-approved forms shall be used to document the
healthcare record.
• An entry made in the healthcare record shall include a legibly printed or ink-stamped
name and title placed in close proximity to the documenter's signature.
Infirmary
Infirmary charting shall be done in accordance with directive 401.06.03.052, Infirmary
Care.
Non-infirmary
Documentation for non-infirmary encounters shall follow the problem-oriented or
subjective, objective, assessment, and plan (SOAP) charting format.
4. Record Management
Storing
The healthcare record must:
• Not be deviated from the approved IDOC format (see appendix A to see where
documents must be maintained in the healthcare record),
• Be maintained in a secure cabinet (located in a secure area),
• Separated from other records pertaining to offenders,
• Be maintained in chronological order within each section, and
• Not be readily available to non-healthcare services staff.
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401.06.03.060
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2.2
Title:
Health Record
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Transferring
The healthcare record must be transferred at the time an offender is transferred to
another IDOC correctional facility. In no event shall an offender be transferred from one
IDOC or contract-operated facility to another IDOC or contract-operated facility without
the healthcare record.
Upon transfer of an offender from one facility to another, the sending facility shall log the
file out and the receiving facility shall log the file in (both using the ‘file transfer’ function
in the Corrections Integrated System [CIS]).
Reactivating
Offenders who are re-incarcerated must have their previous healthcare record
reactivated upon each admission. Reactivation requires that the previous healthcare
record be obtained and all current healthcare documentation placed within the previous
healthcare record. The previous healthcare record can be requested by contacting the
IDOC’s Central Records Unit (located at Central Office).
Thinning
• When necessary, the healthcare record may be thinned (i.e., documents
transferred to an ‘extended file’). However, the healthcare record must always
maintain at least one year of documentation. For healthcare records that remain
too large even with one year of documentation left in them, an ‘exemption’ sticker
may be requested from the IDOC’s Medical Unit (located at Central Office). The
‘exemption’ sticker will allow less than one year of documentation to be
maintained in the healthcare record.
• Extended files must be kept in an expanding file jacket and must be a different
file type than the healthcare record.
• Problem lists, advanced directives, immunization records, history questionnaires,
health assessments, lab tests, imaging, electrocardiograms (EKGs),
electroencephalograms (EEGs), and any other diagnostic testing must never be
removed from the healthcare record.
• When possible, all off-site consult reports will be left in the healthcare record. If
not possible, maintain at least the most recent year in the healthcare record and
transfer the remaining previous years to the extended file.
5. Compliance
Compliance with this SOP and all related IDOC-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 per year, per facility (or more
frequently as desired based on prior audit results). The audits must consist of monitoring
applicable contract medical provider, IDOC policy and procedures, applicable NCCHC
standards, and the review of a minimum of 15 individual records.
Note: Healthcare records shall be available at all times for audit and inspection.
REFERENCES
Appendix A, Healthcare Record Format
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National Commission on Correctional Health Care (NCCHC), Standards for Health Services
in Prisons, Standard P-H-01, Health Record Format and Contents
Directive 401.06.03.052, Infirmary Care
– End of Document –
IDAHO DEPARTMENT OF CORRECTION
Healthcare Record Format
Appendix A
401.06.03.060
(Appendix last updated 5/30/12)
The healthcare record consists of a six-part folder, and the individual documents must be filed in the applicable part of the folder, as
indicated.
Part A Part B
Problem List (All together in chronological order) Physician Order Sheet
Advance Directive Progress Notes
Immunization Record (All together in chronological order) Interdisciplinary Progress Notes (Not nursing protocols)
TB Annual Screenings, HIV Screenings, Etc.
Cautions/IMITS/Alerts
History & Physicals MARS
History Questionnaire Medication Administration Records
Health Assessments and Physicals Non-formulary Pharmacy Request
Lab Treatments
All Laboratory and Pathology Reports Treatment Records
Imaging BS/WT/BP Flow Sheet, Intake or Output
X-ray, Ultrasound, CT & MRI Reports, including Off-site Radiology
Reports.
Consults
Consult Notes
Emergency Service Utilization Reports
Wet Reading Reports Off-site Authorization Request
Diagnostics ER Reports
EKG, EEG, & Audiology Reports (All together)
Ophthalmology (All together)
Receipt of Eyeglasses/Eyeglass Replacement Form
Part C Part D
Health Service Requests (Kites)(Except dental) Intra-system Transfer Forms
All Nursing Protocols Release to Community Forms/Discharge Release Forms
Disposition Response Forms Medical Diet Authorization
Segregation/Detention Forms (Under colored paper under kites)
Receipt for Medical Products (Except eyeglasses)
Food Service Worker Clearance
Offender Healthcare Orientation
Grievances and Offender Concern Forms do not go in the
Healthcare Record Medical Status Report
Chronic Care
Part E Part F
Release of Healthcare Information OB/GYN
Release of Liability
OB/GYN Records, Including Post Partum Orders (File OB/GYN labs in
‘lab’ section)
All Refusals Including Refusals for Physicals (Ultrasound Reports are Filed in ‘Imaging’ Section)
Release of Responsibility Dental
Reimbursements Dental Health Service Requests (Kites)
Power of Attorney Dental X-rays
Waiver of Childproof Container Dental Supplementary Notes
Consent Tab Dental History Forms
All Consent Forms Including Dental Consents, Physical Consents,
Mental Health Consents, Etc. Dental Treatment Record
Mental Health Infirmary
Evaluations & Assessments Infirmary Admission Record
Mental Health Evaluation Infirmary Discharge Record
Level of Care (LOC) Nursing Assessment
Psychiatric Evaluation, AIMS, Etc. Admission Orders
Suicide Risk Assessment History
Treatment Plans/Multidisciplinary Outside Hospital Records
All Treatment Plans from the Interdisciplinary Treatment Team Old Records Requested with Copy of Records Releases.
Progress Notes/Clinical Contact Notes County Jail Records and Transfer Forms from County Jails.
Psychiatry Progress Notes/Clinical Contact Notes (Provider orders
go in the ‘physician order’ section)
Clinical Progress Notes
Tele-psych Notes Note: Infirmary Dr.'s orders, diagnostic tests, and progress notes are to
be filed in their proper place within the chart.
Note: Old healthcare records, from prior incarcerations, are not filed in
the ‘history’ section.
Miscellaneous
Mental Health Observation Forms
Mental Health Referral Forms