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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 />5 of 6 <br /> <br />Transferring <br />The healthcare record must be transferred at the time an offender is transferred to <br />another IDOC correctional facility. In no event shall an offender be transferred from one <br />IDOC or contract-operated facility to another IDOC or contract-operated facility without <br />the healthcare record. <br />Upon transfer of an offender from one facility to another, the sending facility shall log the <br />file out and the receiving facility shall log the file in (both using the ‘file transfer’ function <br />in the Corrections Integrated System [CIS]). <br />Reactivating <br />Offenders who are re-incarcerated must have their previous healthcare record <br />reactivated upon each admission. Reactivation requires that the previous healthcare <br />record be obtained and all current healthcare documentation placed within the previous <br />healthcare record. The previous healthcare record can be requested by contacting the <br />IDOC’s Central Records Unit (located at Central Office). <br />Thinning <br />• When necessary, the healthcare record may be thinned (i.e., documents <br />transferred to an ‘extended file’). However, the healthcare record must always <br />maintain at least one year of documentation. For healthcare records that remain <br />too large even with one year of documentation left in them, an ‘exemption’ sticker <br />may be requested from the IDOC’s Medical Unit (located at Central Office). The <br />‘exemption’ sticker will allow less than one year of documentation to be <br />maintained in the healthcare record. <br />• Extended files must be kept in an expanding file jacket and must be a different <br />file type than the healthcare record. <br />• Problem lists, advanced directives, immunization records, history questionnaires, <br />health assessments, lab tests, imaging, electrocardiograms (EKGs), <br />electroencephalograms (EEGs), and any other diagnostic testing must never be <br />removed from the healthcare record. <br />• When possible, all off-site consult reports will be left in the healthcare record. If <br />not possible, maintain at least the most recent year in the healthcare record and <br />transfer the remaining previous years to the extended file. <br />5. Compliance <br />Compliance with this SOP and all related IDOC-approved protocols will be monitored by the <br />health authority (or designee) by using various sources to include: this SOP, clinical practice <br />guidelines, routine reports, program reviews, and record reviews. <br />The health authority (or designee) must conduct two (2) audits per year, per facility (or more <br />frequently as desired based on prior audit results). The audits must consist of monitoring <br />applicable contract medical provider, IDOC policy and procedures, applicable NCCHC <br />standards, and the review of a minimum of 15 individual records. <br />Note: Healthcare records shall be available at all times for audit and inspection. <br />REFERENCES <br />Appendix A, Healthcare Record Format