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Control Number: 401.06.03.060 Version: 2.2 Title: Health Record Page Number: 3 of 6 In addition, to the above responsibilities, the facility health authority and the facility medical director (or designee) will be jointly responsible for ensuring the presence of an adequate number of appropriately trained staff and materials are available to meet the requirements of this SOP; Table of Contents General Requirements ......................................................................................................... 3 1. Introduction .................................................................................................................... 3 2. Elements of the Healthcare Record ................................................................................ 3 3. Documentation Requirements ........................................................................................ 4 Infirmary ................................................................................................................... 4 Non-infirmary ............................................................................................................ 4 4. Record Management ...................................................................................................... 4 Storing ...................................................................................................................... 4 Transferring .............................................................................................................. 5 Reactivating .............................................................................................................. 5 Thinning .................................................................................................................... 5 5. Compliance .................................................................................................................... 5 References ........................................................................................................................... 5 GENERAL REQUIREMENTS 1. Introduction The healthcare record is the primary tool used by healthcare services staff to manage the assessment, treatment, and care of patients. The IDOC uses the problem-oriented structure to organize the healthcare record. Standardizing the healthcare record enhances the quality of healthcare services, promotes continuity of patient care and treatment, and ensures consistent and accurate records throughout the IDOC. 2. Elements of the Healthcare Record At a minimum, the healthcare record shall contain the following elements: • Identification information (e.g., inmate name, IDOC identification number, date of birth, and sex); • A problem list containing medical and mental health diagnoses and treatments as well as known allergies; • Intake and transfer screening forms; • Health assessment forms; • Progress notes of all significant findings, diagnoses, treatments, and dispositions; • Provider orders for prescribed medication and medication administration records;