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					                                       Effective Date: 9/10/2009              NUMBER: H-60.1
  CORRECTIONAL MANAGED
       HEALTH CARE                     Replaces: 04/07
      POLICY MANUAL
                                       Formulated: 6/85
                                                                              Page 1 of 3

                  HEALTH RECORDS – ORGANIZATION AND MAINTENANCE

PURPOSE: To provide guidelines for development, utilization and management of offender health records
and to establish guidelines for correct documentation in the health record.

POLICY: Health records (paper and/or electronic) on each offender are maintained consistent with
applicable laws and in accordance with a national accrediting body.

   I.     The health record shall contain the following information:
          1. Identification data
          2. Problem List or Summary in electronic medical record (including allergies, special needs,
               chronic clinics, monolingual Spanish speaking status, etc.)
          3. Receiving-screening and health assessment forms
          4. Prescribed medications and therapeutic orders
          5. Reports of laboratory, x-ray and diagnostic studies
          6. Clinic notes
          7. Special needs treatment plans, if any
          8. Immunization records
          9. All findings, diagnoses, treatments and dispositions
          10. Informed consent, refusal forms and release of information forms
          11. All consultants and procedural results
          12. Discharge summaries of inpatient admissions and hospitalizations
          13. Place, date and time of each medical encounter
          14. Signature and title of each documenter (including electronic)
          15. Panorex and other dental x-rays
   II.    All existing paper health records must be filed in reverse chronological order as indicated on
          Attachment A-1. All electronic health records must be documented as indicated on the List of
          EMR Chart Section and Document Types Available as indicated on Attachment A-2. Offender
          electronic medical records may be sorted according to: Section Descending/Scan Date, Scan
          Date/ Document Descending, Document Descending/Scan Date, Section Descending/Service
          Date, Service Date/Document Descending, and Document Descending/Service Date. (See
          Attachment B)
   III.   All services rendered either hands-on care or indirect care (e.g., radiological interpretations), must
          be documented in the patient’s health record on or about the time treatment is provided or
          observations are made by the appropriate health care provider. The offender’s health record will
          be made available to the healthcare provider during encounters. Entries made by clerical staff
          (i.e., scheduling clerks, dental clerks, etc…) shall be restricted to administrative matters only.
          Each entry in the health record must be legible, in chronological order with no blank lines
          between entries and must contain the date and time of the entry and the legible signature and title,
          credentials, rubber stamp with authentication, or electronic signature including credentials of the
          person making the entry. Documentation in the health record will either be entered into the
          offender’s electronic medical record or should only be entered with black ink. White out or
          correction tape is never to be used in the health record. Entries should be written on the lines
          provided and not in the margins. If necessary, continuation of entry is permitted on the following
                                     Effective Date: 9/10/2009             NUMBER: H-60.1
CORRECTIONAL MANAGED
     HEALTH CARE                     Replaces: 04/07
    POLICY MANUAL
                                     Formulated: 6/85
                                                                           Page 2 of 3

               HEALTH RECORDS – ORGANIZATION AND MAINTENANCE

        page by documenting: continued from previous page, date time. Corrections to documentation
        are to be made by drawing a single line through the entry, writing the word “error” and initialing.
         When documentation of a late entry is needed, a separate clinic note must be created within the
        electronic medical record system. (Ex: 1/2/07 3:00pm Late Entry for 1/2/07 9:00am) Electronic
        late entries must be documented on a new document to include the date and time the entry should
        have been made. Documenting on an electronic document that is already electronically signed is
        not permitted.
IV.     All mid-level practitioner orders should be co-signed within 72 hours, or in medically
        underserved areas, a minimum of 10% of mid-level practitioner orders must be co-signed by a
        physician on the next visit as approved by law. Controlled drugs must be co-signed within 24
        hours (72 hours on weekends) and must include date, time, signature and credentials of the
        practitioner.
        All providers of direct care should utilize a format that includes subjective data, objective
        findings, assessment and a plan in the recording of patient evaluations.
V.      Only approved Health Services forms or electronic documents are authorized for permanent
        inclusion in the health record. Use of unapproved forms or electronic documents or modifications
        to approved forms is not authorized for permanent inclusion in the health record. To avoid
        misinterpretations, only symbols and abbreviations on the approved list found on Attachment C
        are permitted. (This does not pertain to the filing of appropriate clinical information.)
VI.      Any existing paper records located on a facility must be thinned when the record reaches 2 inches
        in thickness. All thinned records must be labeled with a volume number. All volumes are to be
        kept on the offender’s facility of assignment and must be transferred when the offender is
        transferred to a new facility of assignment.
VII.    The facility medical records staff or designee assures that each record is reviewed for
        completeness prior to discharging the patient from the EMR. In the event a record is incomplete
        due to death, resignation, termination or incapacitation of the attending physician, the record shall
        be given to the unit health authority (TTUHSC)/facility medical director (UTMB-CMC), or, if
        he/she is the person who is no longer available, the next level medical director will determine if
        some other physician on the staff can accurately and appropriately complete the record.
VIII.   If the record cannot be completed by another physician on staff, the “filed incomplete” form
        (Attachment D) is to be locally produced, completed and signed by the unit health
        authority/facility medical director and the health records supervisor or designee and scanned into
        the offender’s electronic medical record.
IX.     Medical alert codes must be assigned to each offender as necessary via the TDCJ Mainframe
        FORVUS system.
X.      All existing Standard Operating Procedures related to the Electronic Medical Record may be
        found on the Correctional Managed Care (CMC) Web.
                               Effective Date: 9/10/2009        NUMBER: H-60.1
  CORRECTIONAL MANAGED
       HEALTH CARE             Replaces: 04/07
      POLICY MANUAL
                               Formulated: 6/85
                                                                Page 3 of 3

             HEALTH RECORDS – ORGANIZATION AND MAINTENANCE


Index:         Health records, maintenance
               Health records, organization

Reference:     2008 NCCHC Standard P-H-01, Health Record Format and Contents (essential)
               2008 NCCHC Standard P-H-04, Management of Health Records (important)
               ACA Standard 4-4366 (Ref 3-4346) Health Appraisal (Non-Mandatory)
               ACA Standard 4-4413 (Ref. 3-4376) Health Records (Non-Mandatory)

				
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