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									                      DOCUMENTATION/MEDICAL RECORD
A medical record is the documentation kept about the medical care of patients. It contains sufficient
information to identify and assess patients and furnish evidence of the appropriate course of the patient‟s
health care by the provider(s) responsible for the delivery of the health care services.

                             GUIDELINES FOR THE MEDICAL RECORD

         All medical records must be filed in a secure location.
         All medical records must be maintained in a standard format with entries and forms in
          chronological order.
         Each form in the record must have the patient‟s name, identification number and clinic identifier.
          These are available on the computer-generated labels C or D – through the CDP System.
         Each patient receiving health care services shall have a record initiated. (Exception: anonymous
          HIV test/counseling patient and court-ordered HIV testing)
         All medical records shall be regarded and maintained as confidential. The record is to be filed at
          the service delivery site where the service is initiated.
         The provider‟s legend must also contain the signature, title of provider, provider‟s initials, and
          employee ID number. It is to be retained permanently and kept current of new certifications or
          license privileges.
         The service providers shall complete medical records promptly during service provision or
          immediately following.
         Records should not be kept in desk drawers and should not be removed from health departments
          except by court order.
         A master patient index must be maintained at each health center.
         LHDs may use a color-coded sticker system on the outside of the Medical Record to denote
          “Tobacco Use Status”. A color-key must be kept at the LHD for reference.
         Red or fluorescent allergy stickers may be displayed on the front of a medical record to alert the
          health care provider of a potential emergency that can interfere with a patient‟s medical care or
         Allergies may also be written in red within a medical record.

Written consent of the patient or legal guardian is required for release of information to those not
otherwise authorized to receive the information. DPH policy permits the sharing of childhood
immunization information with other LHDs within and outside the state as well as other facilities or
institutions which require evidence of immunizations pursuant to state law, and other providers outside of
the LHD who are providing health care to the patients simultaneously or subsequently.


         LEP, Limited English Proficiency persons are defined as persons who cannot speak, read, write,
          or understand the English language at a level that permits them to interact effectively with
          providers. Other patients that need interpreters: persons who speak more English than they
          understand, persons who understand more than they speak, and those that request an interpreter.
          For any patient that demonstrates the above, use an interpreter.
         Language access is defined as: Providing interpreter (verbal) and translation (written) services to
          those LEP persons at no cost and without unreasonable delay.

                                                     Page 1 of 20
                                       Kentucky Public Health Practice Reference
                                       Section: Documentation/Medical Records
                                                  January 31, 2009
       Working with an interpreter effectively even if the provider is not bilingual is possible. By
        learning about the roles of an interpreter, interpretation techniques, ethics of interpreters,
        professional instinct, and being aware of body language cues (especially side conversations that
        can take place between interpreter and patient) non-bilingual providers can maintain control of
        the interview and establish a good patient/provider rapport.
       Use of a pre-session with all interpreters to establish your “ground rules” for the interpreted
       The use of interpreters or translators must still provide the same level of confidentiality afforded
        to non-LEP customers of the LHD.
       Using an interpreter correctly will ensure accurate documentation and provide for early
       Children, intimate partners, friends and other family should not be used as interpreters if at all
        possible as this could compromise service effectiveness and result in breach of confidentiality.
       Always speak directly to the patient. Avoid addressing the interpreter and saying, “ask her/him”.
        Remember, if your patient spoke English, you would address her/him directly.
       Speak in short sentences and remember not to use slang or jargon…there may not be a linguistic
        equivalent in the second language.
       Ask the patient to repeat to you what you have discussed so that you can check for understanding.
       The services of an interpreter or interpretive phone service must be utilized if LHD staff is unable
        to communicate with the customer well enough to provide services, even if the customer says that
        he/she does not need an interpreter and declines free interpretation services.


       Document the language that the patient speaks in the medical record on initial visit, then update
        as needed.
       Document the steps taken to arrange for an interpreter.
       A master list of names and phone numbers of available interpreters is recommended to be on file
        in the agency.
       If an interpreter was used to obtain a patient‟s consent, record the interpreter‟s name in the
        medical record.
       If a family member acted as an interpreter, record in the medical document that the patient agreed
        to this.
       Document any language needs on referral forms to other providers of LEP persons.
       If a LEP person declines free services and asks to use a relative or friend, staff must document in
        the medical record that the offer was declined and then request that a qualified interpreter sit in on
        the interview or use interpretive phone services to ensure accurate interpretation during the visit.
       For further guidelines, see the Operations and Compliance Section of the Administrative

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                                      Kentucky Public Health Practice Reference
                                      Section: Documentation/Medical Records
                                                 January 31, 2009
1. Charting the Facts
      a. The medical record should contain factual information, not what was inferred by the
           patient or assumed by the provider.
      b. When documenting an observation, be able to back them up with facts, not conclusions.
      c. When documenting a patient‟s behavior, be objective when describing noncompliant
           actions. Behavior is considered noncompliant when the patient‟s actions are inconsistent
           with what has been prescribed or ordered, and not in the patient‟s own best interests.
      d. Do not get personal in your entries. Never let your personal values or judgments about a
           patient or his/her behaviors enter your notes.
      e. Avoid use of derogatory adjectives, however if the patient‟s appearance or behavior is
           relevant to the patient, his problems, treatment, and care, document in objective terms;
           i.e., rather than saying the “patient was rude and unresponsive”, record “patient did not
           respond to history questions and refused to allow blood to be drawn”.
      f. Where possible, use quotes from patients on important elements of history or complaints.
           Reflect the patient‟s own words with quotation marks or if unable to recall exact words,
           try to paraphrase as closely as possible.
2. Accuracy
      a. Accuracy in charting means recording all of the significant details to preserve a complete
           picture of what was done. Which details are “significant” is a matter for your clinical
      b. Generally, it is better to chart more rather than less.
      c. Avoid reliance on “canned” entries – Often good charting will require you to go beyond
           data required to fill out a checklist.
      d. One way to gauge how much to chart is the sensitivity or risk of the procedure in
      e. If you sense that a situation may become controversial, detailed accurate charting can be
           one of your best defensive tools if questions or challenges are later made.
      f. Avoid entries that make it appear that an event happened other than it really did.
      g. Never chart for anyone else or let anyone else chart for you. If it is necessary for this to
           happen, clearly show that you are making an entry for someone else, and the reason why.
      h. Countersigning an entry means that you have reviewed the entry and approved the care
           given; be sure that you have read the entry prior to signing.
      i. Always be aware of “Not Charted-Not Done” – relying on “routine practice” to prove
           that something occurred in a given case is much less credible than if the event is charted
      j. Do not erase, use whiteout or otherwise obliterate a mistaken entry.
      k. Never do anything in correcting an entry that may lead to an accusation that the record
           has been “altered”, or that something has been “covered up”.
      l. Correction should be made as follows:
                  i. Draw a straight line through the mistaken entry so that it remains legible and date
                     when change was made.
                 ii. Sign your name or initial beside the mistaken entry.
      m. Fill in all blanks, it is important there are no blank spaces in a medical record. Blank or
           partially blank pages should be “X‟d” out.
      n. If you do not fill a line, draw a line to the right margin and sign there.
      o. When starting a new entry, start on the line immediately below the last entry.

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                                 Kentucky Public Health Practice Reference
                                 Section: Documentation/Medical Records
                                            January 31, 2009
      p. If it is necessary to go to a new page, and the previous page is not filled, cross out the
           blank spaces. Leaving blank spaces exposes you to questions that you may have gone
           back and “filled in” information.
      q. Do not discard original pages:
                 i. If an original page is somehow rendered unusable, i.e. a coffee spill, recopying
                    that page is acceptable, but it must be indicated on the recopied page that it is
                    recopied, and the date that it was done.
                ii. Do not destroy active medical records; this leads to questions of falsification or
                    “covering up” records.
3. Timeliness
      a. Entries should always be dated and recording data should be done at the same time as
           patient care.
      b. Also it is good to reflect the time of day, although this is less critical than the date in an
           outpatient setting.
      c. Late entries should reflect the date/time entry is made, and reflect date/time of the event
           being referenced.
      d. Make the late entry in the next available space, do not try to squeeze in or write in
      e. Identify the entry as a late entry, and cross-reference to the part of the chart being
4. Miscellaneous
      a. Never include names of individuals other than the patient unless referring to another
           medical/health care professional/interpreter within the context of their
           medical/professional practice, i.e. a referral to or from a provider.
      b. Do not use slang or abbreviations for unflattering references to the patient or his/her
      c. Do not reference incident reports in the medical record. Record the objective facts of an
           event and do not draw subjective conclusions.
      d. Do not use a medical record to point fingers or assign blame.
      e. Handwriting should be neat and legible.
      f. If your script is poor, PRINT.
      g. Poor handwriting may lead to confusion or misunderstanding among health care
           professionals, which may lead to patient injury or other adverse events.
      h. Poor handwriting will also reflect poorly on the professional when others, i.e. a Court,
           lawyers, and/or jury, are trying to read them to determine liability.
      i. Bad grammar and misspellings also reflect poorly on the medical professional and may
           lead to confusion when interpreting medical documentation.
      j. It is important to document all patient telephone calls.
      k. Document problem/reason of the call, and any advice or instruction given. The date and
           time of call should be noted as well.
      l. Telephone calls should be treated no differently than an in-patient visit as far as
           documentation requirements.
      m. Medical records should always reflect “No Shows”, when a patient is noncompliant in
           keeping appointments.
      n. All telephone calls to a physician regarding a patient‟s care should be documented in that
           patient‟s medical record. The documentation should reflect that this conversation was by
           telephone with the patient‟s physician, reason for the call, action taken and the date/time
           call was made or received.

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                                 Kentucky Public Health Practice Reference
                                 Section: Documentation/Medical Records
                                            January 31, 2009
                          DOCUMENTATION GUIDELINES
Documentation should contain the following:

        1) Reason for the encounter and relevant history, i.e., History of Present Illness; Review of
           Systems; Past, Family, and/or Social History. (Subjective)

        1) Physical findings and prior or current diagnostic test results, i.e., General Multisystem
           Exam, Diagnostic Procedures Ordered. (Objective)

         1) Assessment and identification of health risk factors, clinical impression or diagnosis, i.e.,
            Presenting Problems Management Options Categories. (Assessment)
         2) Plan for care, i.e., recommendations, prescriptions for medications, diet or exercise
            modification, health education and counseling, and a plan of return to clinic. i.e.,
            Management Options. (Plan)
         3) Date and legible identity of provider.

All entries must be signed and dated by the provider, including name and title. The signature must
contain first initial, last name and title. Provider initials are acceptable on any form where space is
prohibitive of the complete signature; however, the provider‟s legend must contain the initials in addition
to the signature for proper identification of the provider.

At present, the only approved medical abbreviations are in the PHPR Abbreviation Section and Marilyn
Fuller DeLong‟s Medical Acronyms, Eponyms & Abbreviations. Other medical abbreviations that are
listed in a medically recognized document may be considered for inclusion in the PHPR if they are
submitted to the PHPR Committee along with the referenced document. Each LHD should keep a log of
non-medical abbreviations that are used in their agency, such as MCHS–Madison County High School,
Tues.–Tuesday, CBH–Central Baptist Hospital, etc.

All handwritten entries made in the medical record must be legible and are to be made in non-erasable
black ink.

Documentation may manifest in the following ways:

        1) Continuous written notation of service(s), materials, goals, etc. provided to the client.
        2) May also include the provision of WIC food instruments or provision of basic nutrition
           group class.

         1) S = Subjective information (e.g., what the patient or caregiver tells you)
         2) O = Objective information (e.g., what is seen through laboratory results, etc.)
         3) A = Assessment information (e.g., description of what you think is happening with the
                client and establishment of goals for the client)
         4) P = Plan information (e.g., description of client goals, understanding, treatment,

                                                   Page 5 of 20
                                     Kentucky Public Health Practice Reference
                                     Section: Documentation/Medical Records
                                                January 31, 2009
                                      TYPE OF HISTORY
      The HPI is a chronological description of the development of the patient‟s present illness from
      the first sign and/or symptoms or from the previous encounter to the present.

LOCATION: Does the history indicate if the s/s are diffused or localized, unilateral or bilateral, fixed or
migratory? i.e. breast tenderness, rt. ankle swollen, discharge from left ear.

QUALITY: A specific pattern of complaint, or character/quality of the s/s. Such as sharp, dull,
throbbing, constant or intermittent, acute or chronic, stable, improving or worsening, malodorous, cloudy
or clear, i.e. sharp abdominal pain, foul vaginal discharge.

SEVERITY: Does the history indicate the presence/severity of any condition/discomfort, sensation or
pain? Or does the history indicate the absence of any condition/discomfort, s/s. i.e. no c/o‟s today, denies
pain with exercise, c/o headache, n/v.

DURATION: Does the history indicate the duration of the s/s or problems? i.e. BTB x 3 mo., pain in left
shoulder for 2 weeks.

TIMING: Does the history indicate the onset or cessation of the s/s or problems? i.e. LMP, EDC, pain
started yesterday

CONTEXT: Does the history describe the patient‟s locale or activity when the s/s began? When is the
problem aggravated or relieved? i.e. pain with exercise, burning upon urination.

MODIFYING FACTORS: Does the history indicate what the patient has done to obtain relief? Has the
patient used OTC drugs or attempted to see a MD and did it improve the condition? Exposure to
STD/HIV, toxins TB, etc.? i.e. seen per MD for URI, Tylenol for headache.

ASSOCIATED S/S: Does the history list any associated s/s? such as n/v, headache, sweating, vaginal
bleeding, rash, etc.?

CHRONIC/INACTIVE CONDITIONS: Does the history indicate the status of at least 3 chronic/inactive
conditions? i.e. hypertension, diabetes, migraine headaches, arthritis, asthma, etc. These can be found
primarily on the CH-13, CH-14.

[1 to 3 = Brief]
[4 to 8 = Extended]

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                                      Kentucky Public Health Practice Reference
                                      Section: Documentation/Medical Records
                                                 January 31, 2009
      ROS is an inventory of body systems obtained through a series of questions seeking to identify
      signs and/or symptoms, which the patient may be experiencing or has experienced.

CONSTITUTIONAL SYMPTOMS: i.e., fever, weight change, appetite, fatigue. i.e. history of weight
loss or gain, decreased or increased appetite, unexplained tiredness.

EYES: sclera, conjunctiva, pupils, etc.

CARDIOVASCULAR: lungs, heart, vascular, abdomen. i.e. SOB

RESPIRATORY: nose, mouth, lungs, heart, peripheral vascular, or skin (nails). i.e. history of asthma,
TB contact.

GASTROINTESTIONAL: eyes – in relation to icterus, mouth & pharynx, lymphatic, abdomen, rectal,
skin – in relation to jaundice, liver, gallbladder.

GENITOURINARY: breasts, abdomen, back, external genitalia, vagina, cervix, uterus, adnexa, ovaries,
penis, scrotum, testicles/epididymis, prostate, spermatic cord.

MUSCULOSKELETAL: joints, muscles, bones, range of motion

INTEGUMENTARY: (skin and/or breast), lymphatic, peripheral vascular, sensory nerves

NEUROLOGICAL: higher cortial function, cranial nerves, motor nerves, coordination, gait and station

PSYCHIATRIC: orientation, mood and affect, thought flow, thought content, attention, concentration,
knowledge, abstract reasoning, judgment, insight, pathological reflexes

ENDOCRINE: thyroid, goiter, tumors



[1 system reviewed = Problem Pertinent]
[2 to 9 systems reviewed = Extended]
[10 or more systems reviewed = Complete]

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                                     Kentucky Public Health Practice Reference
                                     Section: Documentation/Medical Records
                                                January 31, 2009

Past History: The patient‟s experience with illness, operations, injuries, and treatment.

       Current medications
       Prior major illness and injury
       Prior operations
       Prior hospitalizations
       Allergies
       Genetic abnormalities
       Age appropriate immunization status

Family History: A review of medical events in the patient‟s family, including diseases that may be
hereditary or place the patient at risk.

       Health status
       Genetic abnormalities
       Cause of death of parents, siblings, children, father of baby
       Specific diseases related to problems identified in the chief complaint, history of present illness,
        and/or review of systems

Social History: An age appropriate review of past and current activities

       Marital status and/or living conditions
       Employment
       Occupational history
       Use of drugs, alcohol and tobacco
       Dietary habits
       Extent of education
       Sexual history

1 item = Pertinent
New patient, 1 item from each of the 3 history areas = Complete
Established patient, 1 item from 2 of the 3 history areas = Complete


                                      HPI                               ROS                   PFSH
   Problem focused                    Brief                             N/A                    N/A
  Expanded problem
                                      Brief                     Problem/Pertinent              N/A
       Detailed                    Extended                          Extended               Pertinent
   Comprehensive                   Extended                          Complete               Complete

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                                      Kentucky Public Health Practice Reference
                                      Section: Documentation/Medical Records
                                                 January 31, 2009

CONSTITUTIONAL:                                  Measurement of any 3 of the following 7 vital signs:
                                                  1) sitting or standing blood pressure, 2) supine blood
                                                  pressure, 3) pulse rate and regularity, 4) respiration, 5)
                                                  temperature, 6) height, 7) weight (May be recorded by
i.e. WN/WD (well nourished, well                  ancillary staff)
developed)                                     General appearance of patient = i.e., development,
                                                  nutrition, body habitus, deformities, attention to
EYES:                                          Inspection of conjunctiva and lids
                                               Examination of pupils and irises (i.e. reaction to light
                                                  and accommodation, size and symmetry)
                                               Ophthalmoscopic examination of optic discs (i.e. size,
                                                  C/D ratio, and appearance) and posterior segments
                                                  (i.e., vessel changes, exudates, hemorrhages)
EARS, NOSE, MOUTH AND THROAT:                  External inspection of ears and nose (i.e., overall
                                                  appearance, scars, lesions, masses)
                                               Otoscopic examination of external auditory canals and
                                                  tympanic membranes
                                               Assessment of hearing (i.e., whispered voice, finger
                                                  rub, tuning fork)
                                               Inspection nasal mucosa, septum and turbinates
                                               Inspection of lips, teeth, and gums
                                               Examination of oropharynx, oral mucosa, salivary
                                                  glands, hard and soft palates, tongue, tonsils and
                                                  posterior pharynx
NECK:                                          Examination of neck (i.e., masses, overall appearance,
                                                  symmetry, tracheal position, crepitus)
                                               Examination of thyroid (i.e., enlargement, tenderness,
RESPIRATORY:                                   Assessment of respiratory effort (i.e., intercostal
                                                  retractions, use of accessory muscles, diaphragmatic
                                               Percussion of chest (i.e., dullness, flatness,
                                               Palpation of chest (i.e., tactile fremitus)
                                               Auscultation of lungs (i.e., breath sounds, adventitious
                                                  sounds, rubs)
                                               Palpation of heart (i.e., location, size, thrills)
CARDIOVASCULAR:                                Auscultation of heart with notation for abnormal
                                                  sounds and murmurs
                                           Examination of:
                                               Carotid arteries (pulse, amplitude, bruits)
                                               Abdominal aorta (size, bruits)
                                               Femoral arteries (pulse, amplitude, bruits)
                                               Pedal pulses (pulse, amplitude)
                                               Extremities for edema and/or varicosities
CHEST: (BREASTS)                               Inspection of breasts (symmetry, nipple discharge)
                                               Palpation of breasts and axillae (masses or lumps,

                                                 Page 9 of 20
                                   Kentucky Public Health Practice Reference
                                   Section: Documentation/Medical Records
                                              January 31, 2009
GASTROINTESTINAL: (ABDOMEN)                 Examination of abdomen with notation of presence of
                                             masses or tenderness
                                          Examination of liver and spleen
                                          Examination for presence or absence of hernia
                                          Examination of anus, perineum and rectum, including
                                             sphincter tone, presence of hemorrhoids, rectal masses
                                          Obtain a stool sample for occult test when indicated
GENITOURINARY:                                                      Male:
                                          Exam of scrotal contents (hydrocele, spermatocele,
                                             tenderness of cord, testicular mass)
                                          Exam of penis
                                          Digital rectal exam of prostate gland (size, symmetry,
                                             nodularity, tenderness)
                                    Pelvic exam with/without collection for smears and cultures,
                                          Exam of external genitalia (general appearance, hair
                                             distribution, lesions) and vagina (general appearance,
                                             estrogen effect, discharge, lesions, pelvic support,
                                             cystocele, rectocele)
                                          Exam of urethra (masses, tenderness, scarring)
                                          Exam of bladder (fullness, masses, tenderness)
                                          Cervix (general appearance, lesions, discharge)
                                          Uterus (size, contour, position, mobility, tenderness,
                                             consistency, descent or support)
                                          Adnexa/parametria (masses, tenderness, organomegaly,
LYMPHATIC:                                Palpation of lymph nodes in 2 or more areas:
                                          Neck
                                          Axillae
                                          Groin
                                          Other
MUSCULOSKELETAL:                          Examination of gait and station
                                          Inspection and/or palpation of digits and nails (clubbing,
                                             cyanosis, inflammatory conditions, petechia, ischemia,
                                             infections, nodes)
                                          Examination of joints, bones, muscles of 1 or more of
                                             the following 6 areas: 1) head and neck, 2) spine, ribs,
                                             and pelvis, 3) right upper extremity, 4) left upper
                                             extremity, 5) right lower extremity, 6) left lower
                                    The examination of a given area includes:
                                          Inspection and/or palpation with notation of presence of
                                             any misalignment, asymmetry, crepitation, defects,
                                             tenderness, masses, effusions
                                          Assessment of range of motion with notation of any
                                             pain, crepitation or contracture
                                          Assessment of stability with notation of any dislocation
                                             (luxation), subluxation, or laxity
                                          Assessment of muscle strength and tone (flaccid, cog
                                             wheel, spastic) with notation of any atrophy or abnormal

                                           Page 10 of 20
                              Kentucky Public Health Practice Reference
                              Section: Documentation/Medical Records
                                         January 31, 2009
SKIN:                                               Inspection of skin and subcutaneous tissue (rashes,
                                                     lesions, ulcers)
i.e. Skin w/d, no rashes or lesions              Palpation of skin and subcutaneous tissue (induration,
                                                     subcutaneous nodules, tightening)
NEUROLOGICAL:                                    Test cranial nerves with notation of any deficits
                                                 Examination of deep tendon reflexes with notation of
                                                     pathological reflexes (Babinski)
                                                 Examination of sensation (touch, pin, vibration,
PSYCHIATRIC:                                     Description of patient‟s judgment and insight
                                            Brief assessment of mental status, including:
i.e. A & O x 4 (alert and oriented)              Orientation of time, place, person, and date
                                                 Recent or remote memory
                                                 Mood and affect (depression, anxiety, agitation)

        Problem Focused                                 1 to 5 elements identified by ()
    Expanded Problem Focused                               6 elements identified by ()
                                                 At least 2 elements identified by () from each
                                                               of the 6 areas/systems
                   Detailed                                              Or
                                                  At least 12 elements identified by () in 2 or
                                                                more areas/systems
               Comprehensive                     At least 2 elements identified by () from each
                                                                 of 9 areas/systems

                                                   Page 11 of 20
                                      Kentucky Public Health Practice Reference
                                      Section: Documentation/Medical Records
                                                 January 31, 2009
                                   DECISION MAKING

1. Number of self limited or minor problems; i.e., cold, insect bite, tinea corporis, headache,
   lice, dermatitis; no apparent contraindications to immunizations/contraceptive methods.
2. Acute uncomplicated illness or injury, i.e., cystitis, URI, allergic rhinitis, pharyngitis, simple
   sprain, STD‟s, OM.
3. Number of chronic illnesses with mild exacerbation, progression, or side effects of treatment,
   i.e., uncontrolled diabetes or hypertension.
4. Undiagnosed new problem with uncertain prognosis, i.e., lump in breast, abnormal pap smear,
   chest pain, developmental delay; true contraindication to immunization/contraceptive
5. Acute condition or illness with systemic symptoms, i.e., pregnancy, pyelonephritis,
   pneumonitis, colitis, TB.
6. Acute complicated injuries, i.e., head injury with loss of consciousness
7. Number of chronic illnesses with severe exacerbation, progression, or side effects of
8. Acute or chronic condition, illness or injury that may pose a threat to life or bodily function,
   i.e., AIDS, high-risk pregnancy.
9. Abrupt change in neurological status, i.e., seizure, TIA, weakness or sensory loss.

Minimal risk =  1 self-limited problem
Low risk =      2 or more self-limiting problems
Low risk =      1 stable chronic illness, well-controlled
Low risk =      1 acute uncomplicated illness or injury
Moderate risk = 1 or more chronic illnesses with mild exacerbation
Moderate risk = 2 or more stable chronic illnesses
Moderate risk = 1 undiagnosed new problem with uncertain prognosis
Moderate risk = 1 acute illness with systemic symptoms
Moderate risk = 1 acute complicated injury
High risk =     1 or more chronic illnesses with severe exacerbation
                1 acute or chronic illness or injury that may pose a threat to life or bodily
High risk =
                1 abrupt change in neurological status, i.e. seizure, TIA, weakness or
High risk =
                sensory loss

                                                Page 12 of 20
                                   Kentucky Public Health Practice Reference
                                   Section: Documentation/Medical Records
                                              January 31, 2009
   Labs performed or ordered

Laboratory tests, venipuncture/capillary; skin tests
X-rays, chest/extremities; EKG/EEG; mammography; axial tomography
Cultures, i.e., strep
Urinalysis, i.e., urine dip, pregnancy tests
Ultrasound, i.e., echocardiography
Cystologic/microscopic tests, i.e., Pap smears, wet preps, hemocults
Developmental tests, i.e., Denver, DASE
Physiologic tests not under stress, i.e., pulmonary function, fetal non-stress, malabsorption allergy
Non-cardiovascular imaging studies with contrast or air injection, i.e., barium enema
Superficial needle biopsies. Skin biopsies.
Blood gases
Physiologic tests under stress, i.e., cardiac stress test, fetal contraction test
Diagnostic endoscopies with no identified risks, i.e., colposcopy
Deep needle, incisional biopsy, excisional biopsy, i.e., conization, LEEP
Cardiovascular imaging studies with contrast and no identified risks, i.e., arteriogram, cardiac cath.
Obtain fluid from body cavity, i.e., lumbar puncture, thoracentesis, culdocentesis, aminocentesis,
Cardiovascular imaging studies with contrast with identified risk factors
Cardiovascular electrophysiological tests
Diagnostic endoscopies with identified risks, i.e., arthroscopy, thoracoscopy, laproscopy
Discography, MRI

Minimal Diagnostic/Assessment = any of the first 6
Low Diagnostic/Assessment = any of the next 5
Moderate Diagnostic/Assessment = any of the next 5
High Diagnostic/Assessment = any of the last 4

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   Performed, Referred or Ordered

Rest, limit activity, guidance for follow-up care. i.e., RTC (appt. date)
Gargles, ointments, creams
Minor procedures – nonsurgical i.e., irrigation of wound or ear
Superficial dressings, bandaids, gauze, elastic bandages, i.e., ACE
Over-the-counter drugs, management/instructions. Ex Condoms
Minor surgery with no identified risk factors
Physical therapy; occupational therapy; skilled nursing (HH)
Counseling, i.e., general diet, behavioral risk, health education
IV fluids without additives
Minor surgery with identified risk factors; emergency room treatment; referral to specialist, i.e.,
OB/GYN, Pediatrician, etc.
Hospital admission with/without elective major surgery (no identified risk factors)
Medical nutritional counseling, referral to RD
Therapeutive nuclear medicine, i.e., radiation treatments
IV fluids with additives, prescriptive drug management, therapeutic injection, i.e., Rocephin,
Closed treatment of fracture or dislocation without manipulation
Subsequent E/M visits for intensive monitoring of high risk pregnancy
Elective major surgery (with identified risk factors)
Emergency major surgery
Parenteral controlled substances, i.e., chemotherapy
Drug therapy requiring intensive monitoring for toxicity

Minimal Management Options = any of the first 4
Low Management Options = any of the next 5
Moderate Management Options = any of the next 6
High Management Options = any of the last 5


                                Problems                         Diagnostic      Management
 Straight Forward                Minimal                          Minimal         Minimal
 Low Complexity                   Low                               Low             Low
Moderate Complexity             Moderate                         Moderate         Moderate
 High Complexity                  High                              High            High

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                   TO SUBPOENAS

The following information outlines consent to release records and responding to subpoenas or
court orders. This information was obtained from „Legal Issues in Public Health Practice‟,
author: Trimble, David, (Oct/Nov 1998).

   1. Who May Consent?
       Obviously, the patient may consent to treatment, and to release his/her records.
       Parent or legal guardian of a minor child (under 18 years old per KRS 2.015) living
         with the parent or guardian.
       Per KRS 214.185, a minor may consent to examination and treatment by a physician
         for STD, pregnancy, alcohol, drug abuse or addiction. Treatment under this section
         does not include abortion or sterilization procedures.
       Per KRS 222.441, a minor may consent to treatment for drug or alcohol abuse, or to
         treatment for the emotional effects of a familial drug or alcohol abuse.
       “Emancipated” minor
         o A minor who is self-supporting and living apart from the parent or guardian, and
             able to understand the procedures and risks.
         o A married minor who is able to understand the procedures and risks (KRS
       A minor who has given birth to a child may consent for the child and herself (KRS
       A minor who seeks treatment for STD, drugs, or alcohol; treatment does not include
         abortion or a sterilization procedure (KRS 214.185).
       A minor who is a victim of a sexual offense may consent to treatment and
         examination of the injuries/effects of the offense (KRS 216B.400).
       Disabled persons who have been adjudged to have mental disabilities cannot consent
         for themselves; they must have a legal guardian appointed for them.
   2. What Constitutes Valid Consent?
      A valid consent to release medical records should consist of:
       A sufficiently specific description of the records to be released so that the producing
         entity may determine which records it is to produce without research or investigation.
       A recognizable signature of the person releasing records, and an identification of the
         person‟s relationship to the patient if other than the patient.
       A witness or notary certification of the signature (recommended but not always
       A statement that the patient understands that by signing the release he/she understands
         that he/she is authorizing the health care provider to release records to the identified
         party, and the patient understands and agrees that he/she will not hold the health care
         provider responsible for disclosure of the records as authorized in the release.
       A specification of the person or entity to which the records are to be released.

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    1. As a general rule, Kentucky does not recognize physician-patient information as
       “privileged”, i.e., protected from disclosure. There are exceptions, however:
        KRS 213.200 – communications with respect to vital statistics
        KRS 421.215 – psychiatrist-patient communications
        KRS 319.111 – psychologist-patient communications
        Federal privilege for protection of drug and alcohol rehabilitation records
        KRS 214.420 – records of STD control activities are confidential, beyond the reach of
            court subpoenas.
    2. The better rule to observe is that set forth by most health-care practice standards groups,
       that all patient records of any type are confidential and should be protected from
       disclosure to unauthorized persons.
    3. Confidentiality should extend even to the fact that a given individual is a patient of a
       given office or agency.
    4. When a question of disclosure comes up, err on the side of caution – consult your
       procedure manuals; consult your administrator; consult your attorney.
    1. A Release is a written document authorizing production or disclosure of medical records
       to another individual or entity.
    2. To be valid, a release must be executed (signed) by the patient, or by a person empowered
       to sign for the patient (see above).
    3. A release over 60 days old generally should not be honored.
    4. A release should specify the nature or type of records sought.
    7. If there are records with combined materials, i.e., a patient who sees several providers
       within a LHD, some of which are privileged and some are not, the protected material may
       have to be “redacted”, or blocked out in the copying process.
       REQUIRES DISCLOSURE OF RECORDS. If you have questions or are uncomfortable
       with disclosing records, consult your Administrator or legal counsel before responding.
    1. A subpoena is a legal document which requires you to attend a legal proceeding at a
       certain date and time, and/or to bring with you certain documents or records.
    2. Court Clerks, at the request of attorneys, issue subpoenas, so they are not court orders.
       However, ignoring a subpoena may result in a court order being issued. THUS, A
    3. If a subpoena seeks records that are protected by one of the above-listed privileges, those
       should not be produced unless you also have a release from the patient or authorized
       person to produce those records. Contact the attorney sending the subpoena, and tell
       him/her that the records are privileged, and contact your attorney for help and advice in
       responding to the subpoena.
    4. To be valid, a subpoena must have been “served”; that is, delivered to you, in specific
       ways: The person delivering must be over eighteen years old; the subpoena must be
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      placed in the HANDS of the person named (mailing is not valid); and the subpoena must
      be served within the court‟s jurisdiction. If these are not met, the subpoena is not valid
      and need not be answered. However, the best practice is to notify the attorney who sent
      the subpoena that it was received but not valid.
   5. KRS 422.330 provides that the assigned records custodian may, in lieu of appearing for a
      deposition, send a certified copy of the subpoenaed records to the person(s) issuing the
   1. A Court Order is a written document issued by a judge that instructs others on actions the
      Court wants taken. Non-compliance with a Court Order can result in personal and
      organizational penalties, and thus prompt compliance is expected.
   2. You should notify your superior if you are asked to respond to a Court Order.
      Consultation with legal counsel may also be advisable if the Court Order instructs the
      release of privileged information and/or confidential documents.
   1. Pursuant to KRS 214.420, records of STD control activities are not subject to court orders
      or subpoenas.
   2. This does not mean you will never receive one.
   3. STD records are limited to specific instances of disclosures, usually limited to those with
      a “specific need to know”, i.e., someone responsible for taking action on behalf of the
   4. If subpoenaed, contact the sender and tell him/her that the records are absolutely
      confidential (if possible without disclosing that the records relate to STD), and seek
      assistance of legal counsel.
   1. On occasion, you may be asked to do more than copy and certify records – you may be
      asked to testify in court or in a deposition.
   2. These forms of testimony differ only in the setting and formality – both are still sworn
      testimony that can or will be relied upon by a judge and/or jury to decide legal issues.
      The same rules apply for a witness in either setting.
   3. TELL THE TRUTH. If you do not know or remember, say so. Guessing is nearly
      always a mistake. If you simply tell the truth, there is no “story” to keep straight.
   4. Listen closely to the question and be sure you understand it before answering. You have
      a right to a fair question you fully understand and have the right to ask for a rephrasing,
      or definition of terms used.
   5. Answer as succinctly as possible. Use “yes” or “no” if those will do. Do not volunteer
      information not asked for.
   6. You have a right to seek advice of counsel during a deposition, but usually not during
      trial testimony. However, as a rule, you must answer a question “on the table” before
      having a private conference with your attorney.
   7. Privileges – things that have been discussed with your attorney for purposes of legal
      advice are considered privileged and may not be asked about. The fact of a discussion
      taking place is OK, but the substance is not. Your attorney should object and instruct you
      IT, AND DO NOT ANSWER IF INSTRUCTED by your attorney.

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   8. Listen to your attorney‟s objections. There are not supposed to be many at a deposition,
      but listen anyway – you may be receiving a tip about how to handle something.

Reference: Trimble, David, (Oct/Nov 1998) “Legal Issues in Public Health Practice”. Frost &
Jacobs, LLP.


KRS Statutes that appear on the confidentiality form are defined below.
209.140 Confidentiality of Information
All information obtained by the department staff or its delegated representatives, as a result of an
investigation made pursuant to this chapter, shall not be divulged to anyone except:

1. Persons suspected of abuse or neglect or exploitation, provided that in such cases names of
   informants may be withheld, unless ordered by the court;
2. Persons within the department or cabinet with a legitimate interest or responsibility related to
   the case;
3. Other medical, psychological, or social service agencies, or law enforcement agencies that
   have a legitimate interest in the case;
4. Cases where a court orders release of such information; and
5. The alleged abused or neglected or exploited person

Effective: July 15, 1980
History: Created 1980 KY Acts Ch. 372, sec. 10, effective July 15, 1980.
Legislative Research Commission Note (1/9/93). Prior references to the “bureau” and the
“department” in this statute were changed to “department” and “cabinet” pursuant to 1982 KY
Acts Ch. 393, sec. 50 (50, and KRS 7.136(2).

209.140 Confidential nature of records
All applications and requests for admission and release, and all certifications, record, and reports
of the Cabinet for Health and Family Services which directly or indirectly identify a patient or
former patient or a person whose hospitalization has been sought, shall be kept confidential and
shall not be disclosed by any person, except insofar as:

1. The person identified or his guardian, if any, shall consent; or
2. Disclosure may be necessary to carry out the provisions of the KRS, and the rules and
   regulations of cabinets and agencies of the Commonwealth of Kentucky; or
3. Disclosure may be necessary to comply with the official inquiries of the departments and
   agencies of the United States Government; or
4. A court may direct upon its determination that disclosure is necessary for the conduct of
   proceedings before it and failure to make such disclosure would be contrary to the public
   interest. Nothing in this section shall preclude the disclosure, upon proper inquiry of the
   family of friends of a patient, of information as to the medical condition of the patient.

Effective: July 15, 1998

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History: Amended 1998 KY Acts Ch. 426, sec. 262, effective July 15, 1998 – Amended 1974
KY Acts Ch. 74, Art. VI, sec. 107(1) and (9). – Created 1954 KY Acts Ch. 12, sec. 1, effective
July 1, 1954

620.50     Immunity for good faith actions or reports – Investigations –
           Confidentiality of Reports

1. Anyone acting upon reasonable cause in the making of a report or acting under KRS 620.030
   to 620.050 in good faith shall have immunity from any liability, civil, or criminal, that might
   otherwise be incurred or imposed. Any such participant shall have the same immunity with
   respect to participation in any judicial proceeding resulting from such report or action.
   However, any person who knowingly makes a false report and does so with malice shall be
   guilty of a Class A misdemeanor.
2. Neither the husband-wife nor any professional-client/patient privilege, except the attorney-
   client and clergy-penitent privilege, shall be grounds for refusing to report under this section
   or for excluding evidence regarding a dependent, neglected, or abused child or the cause
   thereof, in any judicial proceedings resulting from a report pursuant to this section. This
   subsection shall also apply in any criminal proceeding in District or Circuit Court regarding a
   dependent, neglected, or abused child.
3. Upon receipt of a report of an abused, neglected, or dependent child pursuant to this chapter,
   the cabinet as the designated agency or its delegated representative shall initiate a prompt
   investigation, take necessary action, and shall offer protective services toward safeguarding
   the welfare of the child. The cabinet shall work toward preventing further dependency,
   neglect, or abuse of the child or any other child under the same care, and preserve and
   strengthen the family, where possible, by enhancing parental capacity for adequate child
4. The report of suspected child abuse, neglect, or dependency and all information obtained by
   the cabinet or its delegated representatives, as a result of an investigation made pursuant to
   this chapter, shall not be divulged to anyone except:
       a. Persons suspected of causing dependency, neglect, or abuse;
       b. The custodial parent or legal guardian of the child alleged to be dependent, neglected,
           or abused;
       c. Persons within the cabinet with a legitimate interest or responsibility related to the
       d. Other medical, psychological, educational, or social service agencies, child care
           administrators, corrections personnel, or law enforcement agencies, including the
           county attorney‟s office, the coroner, and the local child fatality response team, that
           have a legitimate interest in the case:
       e. A non-custodial parent when the dependency, neglect, or abuse is substantiated;
       f. Members of multidisciplinary teams as defined by KRS 620.020 and which operate
           pursuant to KRS 431.600; or
       g. Those persons so authorized by court order.
5. The identity of informants shall not be divulged to anyone without a court order after the
   court has reviewed in camera the record of the state related to the report or complaint and has
   found it has reason to believe that the informant knowingly made a false report, excepting
   law enforcement agencies having a legitimate interest in the case.

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6. The cabinet, in a case may publicly disclose information where the child abuse or neglect has
   resulted in a child fatality or near fatality.
7. When an adult who is the subject of information made confidential by subsection (4) of this
   section publicly reveals or causes to be revealed any significant part of the confidential
   matter or information, the confidentiality afforded by subsection (4) of this section is
   presumed voluntarily waived and confidential information and records about the person
   making or causing the public disclosure, not already disclosed but related to the information
   made public, may be disclosed if disclosure is in the best interest of the child or is necessary
   for the administration of the cabinet‟s duties under this chapter.
8. As a result of any report of suspected child abuse or neglect, photographs and x-rays or other
   appropriate medical diagnostic procedures may be taken or caused to be taken, without the
   consent of the parent or other person exercising custodial control or supervision of the child,
   as a part of the medical evaluation or investigation of such reports. Such photographs and x-
   rays or result of other medical diagnostic procedures may be introduced into evidence in any
   subsequent judicial proceedings. The person performing the diagnostic procedures or taking
   such photographs or x-rays shall be immune from criminal or civil liability for having
   performed the act. Nothing herein shall limit liability for negligence.

Effective: July 15, 1998
History: Amended 1998 KY Acts Ch. 57, sec. 19, effective March 17, 1998; and Ch. 303, sec.
2, effective July 15, 1998. – Amended 1996 KY Acts Ch. 18, sec. 6, effective July 15, 1996; and
Ch. 347, sec.7, effective July 15, 1996. – Amended 1988 KY Acts Ch. 350, sec. 45, effective
April 10, 1988. – Created 1986 KY Acts Ch. 423, sec. 66, effective July 1, 1987
         Legislative Research Commission Note (7/15/98). This section was amended by
            1998 KY Acts Chs. 57 and 303 which do not appear to be in conflict and have been
            codified together.

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