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IDAHO DEPARTMENT OF CORRECTION <br />Healthcare Record Format <br />Appendix A <br />401.06.03.060 <br />(Appendix last updated 5/30/12) <br />The healthcare record consists of a six-part folder, and the individual documents must be filed in the applicable part of the folder, as <br />indicated. <br />Part A Part B <br />Problem List (All together in chronological order) Physician Order Sheet <br />Advance Directive Progress Notes <br />Immunization Record (All together in chronological order) Interdisciplinary Progress Notes (Not nursing protocols) <br />TB Annual Screenings, HIV Screenings, Etc. <br />Cautions/IMITS/Alerts <br />History & Physicals MARS <br />History Questionnaire Medication Administration Records <br />Health Assessments and Physicals Non-formulary Pharmacy Request <br />Lab Treatments <br />All Laboratory and Pathology Reports Treatment Records <br />Imaging BS/WT/BP Flow Sheet, Intake or Output <br />X-ray, Ultrasound, CT & MRI Reports, including Off-site Radiology <br />Reports. <br />Consults <br />Consult Notes <br />Emergency Service Utilization Reports <br />Wet Reading Reports Off-site Authorization Request <br />Diagnostics ER Reports <br />EKG, EEG, & Audiology Reports (All together) <br />Ophthalmology (All together) <br />Receipt of Eyeglasses/Eyeglass Replacement Form <br />Part C Part D <br />Health Service Requests (Kites)(Except dental) Intra-system Transfer Forms <br />All Nursing Protocols Release to Community Forms/Discharge Release Forms <br />Disposition Response Forms Medical Diet Authorization <br />Segregation/Detention Forms (Under colored paper under kites) <br />Receipt for Medical Products (Except eyeglasses) <br />Food Service Worker Clearance <br />Offender Healthcare Orientation <br />Grievances and Offender Concern Forms do not go in the <br />Healthcare Record Medical Status Report <br /> Chronic Care <br />Part E Part F <br />Release of Healthcare Information OB/GYN <br />Release of Liability <br />OB/GYN Records, Including Post Partum Orders (File OB/GYN labs in <br />‘lab’ section) <br />All Refusals Including Refusals for Physicals (Ultrasound Reports are Filed in ‘Imaging’ Section) <br />Release of Responsibility Dental <br />Reimbursements Dental Health Service Requests (Kites) <br />Power of Attorney Dental X-rays <br />Waiver of Childproof Container Dental Supplementary Notes <br />Consent Tab Dental History Forms <br />All Consent Forms Including Dental Consents, Physical Consents, <br />Mental Health Consents, Etc. Dental Treatment Record <br />Mental Health Infirmary <br />Evaluations & Assessments Infirmary Admission Record <br />Mental Health Evaluation Infirmary Discharge Record <br />Level of Care (LOC) Nursing Assessment <br />Psychiatric Evaluation, AIMS, Etc. Admission Orders <br />Suicide Risk Assessment History <br />Treatment Plans/Multidisciplinary Outside Hospital Records <br />All Treatment Plans from the Interdisciplinary Treatment Team Old Records Requested with Copy of Records Releases. <br />Progress Notes/Clinical Contact Notes County Jail Records and Transfer Forms from County Jails. <br />Psychiatry Progress Notes/Clinical Contact Notes (Provider orders <br />go in the ‘physician order’ section) <br />Clinical Progress Notes <br />Tele-psych Notes Note: Infirmary Dr.'s orders, diagnostic tests, and progress notes are to <br />be filed in their proper place within the chart. <br />Note: Old healthcare records, from prior incarcerations, are not filed in <br />the ‘history’ section. <br />Miscellaneous <br />Mental Health Observation Forms <br />Mental Health Referral Forms <br />