Prepare appropriate documentation regarding inmate health status and deliver it to appropriate transporting staff prior to the transfer of an inmate.

Review all documentation regarding health status of a received inmate and, when appropriate, evaluate the inmate in a timely manner following arrival.

Make appropriate documentation entries in the Department medical record regarding the transfer of medical information.

Maintain, retain, transfer and dispose of inmate medical records in accordance with this Department Order.

Release medical information in accordance with this Department Order to the Director and Assistant Directors, and to Wardens and Deputy Wardens of correctional facilities.

Release medical information and maintain its confidentiality in accordance with this Department Order.

The Deputy Director for Prison Operations is responsible for ensuring that appropriate staff:

Notify Health Services staff, in a timely manner, of the pending arrival/transfer of an inmate within the Department's system or outside of the Department's system.

Deliver medical documentation from the transporting facility to the receiving facility health staff, and in certain specified cases, ensure that the inmate is delivered to the health unit for evaluation by the health services staff.

Authorized recipients of inmate medical history information are responsible for ensuring that the information is used only in accordance with this Department Order and not disseminated to others.

1.1.1 Facility health administrators shall provide appropriate inmate medical history information to an authorized recipient upon the authorized recipient's request.

1.1.2 Authorized recipients of the medical information shall request appropriate inmate medical history information from the Facility Health Administrator when there is a correctional-related reason to do so.

1.2 Using Inmate Medical History Information - Authorized recipients (The Director, Deputy Directors, Assistant Directors, Regional Operations Directors, Wardens and Deputy Wardens, who are authorized by A.R.S. 41-1606 to receive inmate medical history information and to use the information for correctional-related purposes) shall ensure that inmate medical history information is used only for correctional-related purposes and that it is not, pursuant to A.R.S. 36-666 and 36-667, secondarily disseminated.

1.1.1 Submit an Inmate Letter, Form 70501168, to medical records staff (or to other Health Services staff designated to perform the medical records functions) to request access.

1.1.2 Specify in the letter what portions of the health record are included in the request.

1.2 The medical records staff (or other Health Services staff designated to perform the medical records functions) shall:

1.2.1 Schedule an appointment for the inmate to review the Unit Health Record in the presence of a Health Services staff member.

1.2.2 Complete and distribute the appropriate pass allowing the inmate to come to the Health Unit for the scheduled appointment.

1.2.3 If an inmate's classification and/or housing assignment preclude allowing the inmate to come to the Health Unit (escorted or unescorted) for the appointment, advise security staff of the appointment.

1.2.3.1 After being advised of the appointment, security staff shall make necessary security arrangements for Health Services staff to safely meet with the inmate at the appropriate location and supervise the inmate's review of the Unit Health Record.

1.2.4 If the review request includes the Mental Health Section of the Unit Health Record, forward the Mental Health Section to a psychiatrist or licensed psychologist, who shall:

1.2.4.1 Determine whether the inmate's review of the Mental Health Section would be detrimental to the inmate's condition or treatment.

1.2.4.2 Document the determination in the Progress Notes of the Mental Health section.

1.2.5 If there is no contraindication to the inmate reviewing the Mental Health Section of the Unit Health Record, schedule the inmate to review the Mental Health Section in the presence of the psychiatrist or licensed psychologist.

1.2.6 If review of the Mental Health Section of the Medical Record is contraindicated for the inmate, verbally advise the inmate that access to the Mental Health Section has been denied.

1.3 Review of Health Records and Mental Health Sections - Medical Records staff or designee or, in the case of the Mental Health Section, the psychiatrist or licensed psychologist, shall ensure that:

1.3.1 The inmate reads the rules governing the medical records review, as contained in the Guidelines for Inmate Medical Records Review, Form 70400089, and then signs the form where indicated.

1.3.2 The Health Records provided for the inmate's review remain in plain view on the table, desk or other work surface throughout the review.

1.3.3 The reviewing inmate makes no notations on or alterations of the Health Record.

1.3.4 The inmate is permitted to make handwritten notes during the review.

1.3.5 A maximum of 45 minutes is allowed for the inmate's review of the Unit Health Record.

1.3.6 At the conclusion of the review and after date and time information is documented on the Guidelines for Inmate Medical Records Reviews form, the inmate is asked to sign the acknowledgment of the review at the bottom of the form.

1.3.7 The Guidelines for Inmate Medical Records Reviews form is filed in Section III of the Unit Health Record, under the Miscellaneous tab.

1.3.8 If the inmate feels that additional time is needed for the review, the inmate is permitted to:

1.3.8.1 Request an additional review.

1.3.8.2 Review the Health Record at a date and time that is convenient and that does not conflict with staff workload priorities.

1.1.1 Forward the request to the Office of the Attorney General, via the Discovery Unit, for advice as to whether the following requirements have been met in relation to the case:

1.1.1.1 The court has stipulated that the inmate may act as his own attorney.

1.1.1.2 The request is related to a bona fide lawsuit that has been validly served on the Department or other defendant.

1.1.1.3 The request for discovery has been filed.

1.1.1.4 The Office of the Attorney General has not filed, in court, an objection to the production of the records.

1.1.2 Upon notification from the Office of the Attorney General that all requirements have been met, ensure that the copies of the appropriate portions of the Unit Health Record are prepared by Health Services staff, who shall give the copies directly to the inmate after the following have been completed:

1.1.2.1 The inmate has signed the Inmate Medical Record Waiver of Liability, Form 70400175.

1.1.2.2 Health Services staff who provided the copies to the inmate sign the Inmate Medical Record Waiver of Liability form as witnesses to the inmate's signature and file the form in the inmate's Unit Health Record.

1.2 Charges for Copies - The Medical Records/Investigations Program Manager shall charge the appropriate fee for the information copied from a Unit Health Record, as follows:

1.2.1 An inmate who is not indigent shall be charged 50 cents for each page.

1.2.2 An indigent inmate who submits a copy of the approved Application for Indigent Status - Health and Welfare, Form 20301017, shall not be charged for copies.

1.1.1 Ensure that Unit Health Records contain information that is sufficiently detailed to:

1.1.1.1 Enable treatment staff to give effective continuing care;

1.1.1.2 Determine the course of treatment at any specific time;

1.1.1.3 Provide a consultant with adequate information to give an opinion after examination of the inmate/patient and review of the medical records;

1.1.1.4 Allow another staff member, not familiar with the case, to determine what has transpired in the management of the patient; and

1.1.1.5 Enable collection and analysis of statistical data pertaining to delivery of health care.

1.1.2 Ensure that staff do not file material/documents other than those approved in accordance with this Department Order.

1.1.3 Establish appropriate retention schedules for all health records of inmates and former inmates in accordance with Department Order #103, Correspondence/Records Control.

1.2 The Facility Health Administrators and supervisors shall ensure that:

1.2.1 All facility health staff properly submit health-related reports and other documentation; and

1.2.2 Inmate health records are submitted to the Medical Record/Investigations Program Manager in the proper health record format.

1.3 Health Records - Check-Out Procedure - Only members of the health staff shall be authorized to check out records.

1.3.1 An out-guide shall be inserted in place of the record.

1.3.2 To the out-guide will be attached a check-out slip containing the following information:

1.3.2.1 The inmate's name and number.

1.3.2.2 Date the chart is removed.

1.3.2.3 Date the chart is to be returned, which shall not be longer than three days following removal.

1.3.2.4 The reason for removal.

1.3.2.5 The signature of individual removing the record.

1.3.3 The individual removing the record shall be responsible for its return within the required time.

1.3.4 Upon replacement of the file, the out-guide and check-out slip shall be removed.

1.3.5 The Health Unit Manager/Supervisor or delegate shall make regular checks, at least weekly, of any records that are overdue. Repeated failures to return records in a timely fashion without adequate reason shall be a cause for disciplinary action.

1.1.1 An Initial/Inter-Facility Assessment, Form 70400121 shall be immediately completed for all inmates upon arrival at a Reception Center. Whenever possible, the Assessment Form shall be completed by a member of the health staff.

1.1.2 In those cases where the form is not completed by a member of the health staff, it shall be reviewed by a member of the health staff as soon as feasible, but in no event later than 24-hours after arrival.

1.1.3 All staff completing an Initial/Inter-Facility Assessment shall have on hand a copy and be informed of the definitions in Department Order #1101, Inmate Access to Health Care; shall make notification of an inmate reporting such a condition; and shall immediately notify a member of the health staff on-duty or on-call.

1.1.4 All staff completing an Initial/Inter-Facility Assessment shall notify mental health staff of any observation of symptoms of mental illness or of an inmate reporting such symptoms or history, such that a provisional determination of serious mental illness can be made with designation of follow-up comprehensive serious mental illness evaluation by a mental health professional.

1.2 Medical History

1.2.1 A Medical History, Form 70400022 shall be completed within 24-hours or arrival of an inmate at a Reception Center. In no circumstances shall completion be later than 72-hours after arrival.

1.2.2 The Medical History form shall be completed by a member of the health staff.

1.2.3 In all cases, the individual completing an Initial/Inter-Facility Assessment or a Medical History shall sign the form.

1.2.4 All staff completing the Medical History shall notify mental health staff of any observation of symptoms of mental illness or of an inmate reporting such symptoms or history, such that a provisional determination of serious mental illness can be made with designation of follow-up comprehensive serious mental illness evaluation by a mental health professional.

1.3 Mental Health Screening

1.3.1 Staff completing an Intake/Inter-Facility Assessment or Medical History who determine from available information or inmate self-report that an inmate has a history of serious mental disorder or mental health treatment shall refer the inmate to mental health staff.

1.3.2 Mental health staff shall evaluate inmates who have been referred because of a history of serious mental disorder or mental health treatment with 48 hours of the referral, excluding weekends and holidays.

1.4 Transfer

1.4.1 Upon arrival at an institution from a Reception Center a member of the health staff of the receiving institution shall review the Initial/Inter-Facility Assessment and Medical History forms.

1.4.2 Within 24 hours of arrival health care/mental health staff shall review medical files of inmates arriving from a Reception Center to ensure that inmates with mental health issues are identified.

1.4.2.1 Inmates identified as having mental health issues shall be referred in a timely manner to appropriate mental health staff for evaluation.

1.4.2.2 Mental health staff shall evaluate inmates identified as having a history of serious mental disorder or mental health treatment within 48 hours of referral, excluding weekends and holidays.

1.5 Health Encounter Form

1.5.1 Documentation of all health encounters shall be made using the S.O.A.P. format:

1.5.1.1 Subjective: This refers to the inmate's complaint - what the inmate says is wrong with him/her.

1.5.1.2 Objective: Refers to all pertinent, positive or negative findings determined by the health provider after history or examination.

1.5.1.3 Assessment: Refers to the provider's assessment of the inmate and shall include inter alia, provisional, definite or differential diagnosis based on the information available at the time of the encounter.

1.5.1.4 Plan or Rx: Refers to a diagnostic work-up including X-rays and laboratory tests. Rx-treatment including any prescription ordered for the inmate, together with the dosage, total amount prescribed, and specific directions for administration.

1.5.2 Documentation shall be immediately made, as required, herein, by every health provider when a health encounter is made. Should two providers make encounters with the same inmate about the same condition (e.g., when a nurse refers an inmate from Sick Call to the Doctor's Line), then both providers shall complete separate S.O.A.P. documentation.

1.5.3 All S.O.A.P. forms shall be placed in the inmate's record.

1.5.4 Inmates requiring special consideration shall have their abilities and limitations documented on the Duty/Special Needs Order, Form 1101-60P.

1.5.5 A copy of the Duty/Special Needs Order shall be distributed to medical records, the inmate, institutional file, and the unit Chief of Security.

1.5.5.1 Medical information relating to the diagnosis of the inmate shall not be noted on the Duty/Special Needs Order.

1.5.5.2 Use of the Duty/Special Needs Order does not negate the need for proper documentation on the Continued Progress Record, Form 1101-62P.

1.6 Laboratory, X-Ray, E.K.G. and Other Ancillary Investigation Reports

1.6.1 Upon receipt of all laboratory, x-ray, EKG, EEG, or other ancillary investigation reports, the report shall be immediately forwarded to the Physician, Dentist or Physicians' Assistant who ordered the test.

1.6.2 Following review, the Physician, Dentist, or Physicians' Assistant will sign the report and as indicated by its results, take such other action as is necessary.

1.6.3 If the report results show that no action is necessary, the report will be filed in the appropriate section of the resident's health record.

1.6.4 No more than three reports shall be affixed to any one page.

1.1.1 Relay information to the FHA regarding the pending arrival of an inmate with oxygen, cpap machine, or other potential health needs issues which the reception center may not be able to handle.

1.1.2 Deliver medical documentation from the sending institution to Inmate Health Services staff.

1.2 Inmate Health Services staff shall:

1.2.1 Verify receipt of the inmate and the inmate's medical information from the sending institution.

1.2.1.1 If no medical information is received at the time of transfer, Inmate Health Services staff shall telephone the jail, request telefax transmittal of the documents, and then prepare an Information Report.

1.2.2 Review the medical documentation received and schedule the inmate for an Intake Health Assessment/Physical Examination and, if indicated, obtain written medical order(s) to provide necessary treatment.

1.3 Upon receipt of notification of the arrival of an inmate with special needs as outlined in section 1.1.1, the FHA or designee shall notify the Central Office Health Services Coordinator to obtain a medical transfer order from the Deputy Director for Inmate Health Services, or designee.

1.4 Upon receipt of the medical transfer order the Central Office Health Services Coordinator shall contact the Central Office Classification Manager to facilitate the inmate’s transfer to the Tucson Health Unit.

1.5 Once the inmate is in a facility capable of managing the inmate’s health needs, the classification process shall occur.

1.6 Inmate Health Services staff shall:

1.6.1 Review the medical record of each transferring inmate and prepare a Continuity of Care/Transfer Summary, Form 70400080.

1.6.2 Place the completed form in an envelope which is sealed and marked "CONFIDENTIAL" and addressed to the receiving institution health staff.

1.6.3 Deliver the envelope to the designated institutional staff for transport to the receiving institution or transporting staff, if other than Departmental transportation staff.

1.6.4 In the event that the transfer takes place on an "emergency basis" so that there is insufficient time for the above to take place, call the receiving institution as soon as they are notified of the inmate's transfer and convey the appropriate information and telefax a completed Continuity of Care/Transfer Summary form.

1.7 Institutional staff shall transport the medical record information in a sealed envelope marked "Confidential" to the receiving institution's health staff.

1101-60P, Duty/Special Needs Order

70400022, Medical History

70400080, Continuity of Care/Transfer Summary

70400121, Initial/Inter-Facility Assessment

70501168, Inmate Letter

70400089, Guidelines for Inmate Medical Records Review

70400175, Inmate Medical Record Waiver of Liability

CORRECTIONAL-RELATED PURPOSE - For the purposes of this Department Order, the reasons that an authorized recipient may receive inmate medical history information and appropriate uses of the information in the management and operation of a correctional facility.

REASONABLE COSTS - For the purposes of this Department Order and in accordance with A.R.S. 12-351, fees of ten cents for each page copied and ten dollars per hour for costs incurred in locating and making documents available, which are charged to a requestor after providing documents in response to a subpoena, all other copy charges are 50 cents per page.

A.R.S. 31-224, Duty of ADC Director to Deliver Medical Records/Information to Receiving Institutions.

A.R.S. 31-132, Duty of County Sheriff's Office to Deliver Medical Records/Information to Receiving Institutions.

A.R.S. 36-661 et seq, Communicable Disease Information.

A.R.S. 41-1606, Access to Prisoner Medical History Information.

A.A.C. R9-6-601., Diseases Declared Communicable.

A.A.C. R9-6-605., Confidentiality of Communicable Disease Information.

SUPERSEDES INFORMATION

Department Order 1104, Inmate Medical Records, supersedes the following:

DMO 94-03, Release of Medical Information (01/27/94)

DMO 94-17, Inmate Access to the Unit Health Record (08/01/94)

IMP 705.0, Uniform Health Record System (1/29/93)

IMP 705.2, Clinical Summary (12/5/83)

IMP 705.3, Initial Health Assessment and Medical History (12/5/83)

IMP 705.4, Health Records - Check-Out Procedure (2/17/84)

IMP 705.5, Health Encounter Form (12/5/83)

IMP 705.7, Laboratory, X-Ray, E.K.G. and Other Ancillary Investigation Reports (12/5/83)

IMP 706.6, Transfer of Medical Summary (10/21/94)