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Section H: Health Records |
J-H-01
Health Record Format and Contents
(Essential) |
Formerly
J-58
This essential standard intends that a health record is
properly created and maintained for inmates. It remains
basically the same regarding documents required to be in
the record. Two compliance indicators make explicit
issues relating to electronic records (same requirements
for electronic records as for paper) and expectations
when separate records are kept by separate disciplines
(there is a process for ensuring that pertinent health
information is shared). |
J-H-02
Confidentiality of Health Records and Information
(Essential)
(Name change for jail from "Confidentiality of
Health Records" to better reflect content.) |
Formerly
J-59
An intent of this essential standard is to protect the
patient’s right to confidentiality of both the health
record and personal health information. It remains
basically the same, and makes explicit that both health
staff and nonhealth staff receive instruction regarding
protecting this right to confidentiality. The explicit
inclusion of health information per se under the
confidentiality umbrella is new to the jail environment. |
J-H-03
Access to Custody Information
(Important)
(Name change from "Sharing of Health
Information" to better reflect content of the
standard.) |
Formerly
J-60
This important standard intends that criminal justice
information that may influence clinical decisions is
available to treating clinicians. It has been changed
from the prior versions so that the focus is on the
access to custody information for health staff. (The
issues related to sharing health information with
custody are covered in essential standard J-A-08
Communication on Special Needs Patients.) |
J-H-04
Availability and Use of Health Records
(Important) |
Formerly
J-61
This important standard intends that the facility has a
system to facilitate health record use so that the
record is used in each scheduled clinical encounter. |
J-H-05
Transfer of Health Records
(Important) |
Formerly
J-62
This important standard intends that the patient’s
health information accompanies the patient during
transit to facilitate continuity of care when the inmate
is transferred to another correctional jurisdiction. It
remains essentially the same as in previous versions
regarding the requirements for the records release
itself. Other standards address issues related to
sending information when the inmate is being moved to
another facility within the system (J-E-03 Transfer
Screening) and to community settings (J- E-13 Discharge
Planning). |
J-H-06
Retention of Health Records
(Important) |
Formerly
J-63
This important standard remains basically the same;
arrangements for electronic records need to be
articulated as well. Automatic reactivation of former
records in the case of a readmitted inmate is not the
issue; the requirement is that former record be
available in a timely manner should the clinician
request reactivation. |
