NCJ Number
116400
Date Published
1988
Length
210 pages
Annotation
This manual provides a reference resource for medical records practitioners and health care professionals in correctional settings.
Abstract
Following an overview of the adult and juvenile correctional health care settings and inmates' right to health care, the medical record department and its personnel are described; and sample policies and procedures are discussed. Components of the health record system are delineated including numbering systems, master index, filing approaches, format and order of assembly, filing equipment, record location, and the outguide system. Guidelines for retention and destruction of records also are discussed, together with the primary and secondary purposes of such records. The content of the inpatient and outpatient health records is enumerated from entry through discharge or transfer. Included are data on physical examinations, problems, treatments, diagnostic studies, immunizations, consultations, authorizations/consents, dental records, and results of eye and hearing examinations. Elements of form design and control are presented, together with considerations affecting design. Standards for accreditation and professional practice are provided, and sample monitoring and quality control data instruments are included. Finally, legal issues surrounding confidentiality, consent and authorizations, use of psychotropic medications, inmate research, and transfer of inmate patients are addressed. Job descriptions, sample policies and procedures, and sample forms are appended. 47-item bibliography.