Standardized Health Record System - Utah State Prison

• NCJ Number: 75692
• Author(s): A M Fiducia
• Date Published: 1978
• Length: 193 pages
• Corporate Author: Florida Dept of Offender Rehabilitation
• Publication Format: Document
• Language: English
• Country: United States of America

Annotation

This looseleaf manual presents findings and recommendations regarding a standardized health record system for the Utah State Prison, developed by a private consultant.

Abstract

Pursuant to request for assistance, the consultant made a site visit to Utah State Prison in August 1978. The warden, associate warden, hospital coordinator, registered nurse, and medical assistant were contacted during the visit. In addition, 25 of the 940 health records of inmates were carefully examined. Problem areas were identified; these problems included the fact that health records were filed alphabetically instead of numerically, allergies and/or chronic diseases were not marked on the health record folders, forms were not securely attached to the folders, and inpatient and outpatient records were maintained in the same folder. Some entries were illegible, prescription medication dispensed by a nurse or assistant was not countersigned by a physician, and followup visits were not scheduled for minor surgical procedures. It is recommended that the prison develop and implement a standardized record folder and forms, samples of which are provided in the manual. Implementation of the standardized health record system should be facilitated by a member of the Utah State Hospital Medical Records Department. The standardized forms included as appendixes are currently used throughout the country by various organizations, such as the Florida Department of Corrections, the United States Air Force, and the Florida Department of Health and Rehabilitative Services. Other forms and directives recommended for use were developed by the Joint Commission on the Accreditation of Hospitals and the Law Enforcement Assistance Administration (LEAA). Categories of these records include standardized health records, policy and procedure directives, clinic services, medical record services, health records, and inmates' medical records. Documents addressing the implementation process are also provided.