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Control Number: <br />401.06.03.060 <br />Version: <br />2.2 <br />Title: <br />Health Record <br />Page Number: <br />4 of 6 <br /> <br />• Reports of laboratory, x-ray, and diagnostic studies; <br />• Flow sheets; <br />• Consent and refusal forms; <br />• Release of information forms; <br />• Results of specialty consultations and off-site referrals; <br />• Discharge summaries of hospitalizations and other in-patient stays; <br />• Special needs treatment plan, if applicable; <br />• Place, date, and time of each clinical encounter; and <br />• Printed name, title, and original signature of each documenter. <br />Note: Any and all changes made to the format and structure of the healthcare record, <br />including the implementation of an electronic medical record (EMR), must be approved in <br />writing in advance of the change being implemented. Such requests must be made in writing <br />to the health authority. <br />3. Documentation Requirements <br />• Each health encounter shall be documented by a healthcare professional. <br />• Except for healthcare records that are generated by community providers or other <br />correctional agencies, only IDOC-approved forms shall be used to document the <br />healthcare record. <br />• An entry made in the healthcare record shall include a legibly printed or ink-stamped <br />name and title placed in close proximity to the documenter's signature. <br />Infirmary <br />Infirmary charting shall be done in accordance with directive 401.06.03.052, Infirmary <br />Care. <br />Non-infirmary <br />Documentation for non-infirmary encounters shall follow the problem-oriented or <br />subjective, objective, assessment, and plan (SOAP) charting format. <br />4. Record Management <br />Storing <br />The healthcare record must: <br />• Not be deviated from the approved IDOC format (see appendix A to see where <br />documents must be maintained in the healthcare record), <br />• Be maintained in a secure cabinet (located in a secure area), <br />• Separated from other records pertaining to offenders, <br />• Be maintained in chronological order within each section, and <br />• Not be readily available to non-healthcare services staff.