Initial Health Assessment

E-04 Initial Health Assessment (essential)

Inmates receive an initial health assessment.
—2014 Standards for Health Services for jails and prisons

In this article, we will examine a standard that is sometimes misinterpreted, leading to potential compliance issues. An initial health assessment in a correctional setting is an essential component of a health care system and the standard has many requirements that must be met to achieve compliance.

Options for Facilities

Standard E-04 is unique in that it gives a jail or prison two options for demonstrating compliance with the standard: Option One, Full Population Assessment, and Option Two, Individual Assessment When Clinically Indicated. The two choices cannot be combined, so once an option is chosen, the compliance indicators for that option must be followed. The standard for juvenile facilities does not offer different options for compliance. The differences for juveniles will be discussed throughout the article.

Option One: Full Population Assessment
This option involves performing an initial health assessment on 100% of incarcerated individuals as soon as possible, but no later than seven days (prisons and juvenile facilities) or 14 days (jails). Facilities should base their decision for scheduling the health assessment on factors such as length of stay, allocation of staff and disease prevalence in the facility or community. For example, in a jail, performing an initial health assessment within two or three days may assist in identifying patients with chronic diseases or those who may be undergoing drug or alcohol withdrawal. In a prison, performing an initial health assessment upon admission may assist in getting patients identified and enrolled in a chronic disease program earlier in their stay.

The components of an initial health assessment on the full population include a review of the receiving screening results; however, we find that this is often omitted or evidence of documenting the review is not annotated with the health assessment encounter, leading to compliance issues. The responsible health authority should ensure that the process for health assessments includes this documented review. A history, vital signs, height and weight may be collected by a qualified health care professional. The history should also include follow-up from positive findings from the receiving screening and subsequent health care encounters leading up to the health assessment.

The hands-on evaluation of the patient involves inspection, palpation, auscultation and percussion of the patient’s body to determine the presence or absence of physical signs of illness. The RHA should ensure that this part of the health assessment is truly a hands-on approach, rather than simply collecting a current health history. The physical exam can be done only by a physician, physician assistant, nurse practitioner or a registered nurse.

Another component that often poses compliance issues is the requirement for laboratory and/or diagnostic testing for communicable diseases. For jails, testing for tuberculosis is required before or during the initial health assessment. For juvenile facilities, tuberculosis testing should be done, unless there is documentation from the health department that the prevalence rate does not warrant it. Unique to the prison standards is the requirement for a pelvic exam or referral for a pelvic exam with or without a Pap smear, when clinically indicated. Immunizations, as needed, are required in all facilities.

Upon completion of the health assessment by an RN, all abnormal findings must be reviewed by the provider (physician, physician assistant or nurse practitioner). If a physician, physician assistant or nurse practitioner performs the initial health assessment, then further review may not be required. However, the treating clinician must update the problem list and develop diagnostic and therapeutic plans for each problem as clinically indicated.

Option Two: Individual Assessment When Clinically Indicated (Jails and Prisons Only)
The individual assessment when clinically indicated has many more requirements than Option One. However, it focuses staff energy and time only on those patients with chronic or acute health care needs. When using this option, it is imperative that the RHA and/or responsible physician clearly define conditions that qualify as clinically significant findings, which is defined as any deviation from the normal that significantly impact the health and safety of the patient.

To qualify for this option, the facility must have on-site health staff coverage 24 hours per day, seven days per week. This option also requires that all individuals receive a comprehensive receiving screening, which must be done only by licensed health care personnel. In addition to meeting the requirements of standard E-02 Receiving Screening, the screening must also inquire into past history and symptoms of chronic diseases, as well as medications, including dosages. A finger-stick blood glucose reading must be obtained on individuals with diabetes during the receiving screening. Finally, vital signs, including pulse, respiration, blood pressure, temperature, height, and weight, must be obtained during receiving screening and then again during the initial health assessment.

Next, within two days of admission, the initial health assessment must be performed by a physician, physician assistant or nurse practitioner. A registered nurse may not perform the physical examination in Option Two. The components of the health assessment are the same as in Option One except that laboratory and/or diagnostic tests for disease, such as a peak flow for asthma patients or blood work for diabetes patients, must be performed.

Juvenile Standard Requirements

The first noticeable difference in the juvenile standards is in the title “Health Assessments.” Whereas jails and prisons require an initial health assessment only, juveniles must receive initial and periodic assessments. The components of the health assessment for juveniles are very similar to Option One for jails and prisons. However, for juveniles, the physical exam should include breast, rectal and genitourinary exams as indicated by gender, age and risk factors. Females should also receive a gynecological assessment when clinically indicated. The responsible physician should determine which laboratory and diagnostic tests should be performed.

In juvenile facilities, the responsible physician must determine the frequency and content of periodic health assessments based on protocols promulgated by nationally recognized professional organizations. Certain elements should be repeated at an appropriate frequency as determined by the responsible physician, in consideration of age, gender and health needs, consistent with the recommendations of professional organizations.

Repeating the Health Assessment

Finally, for all facility types, when a patient is released and readmitted and a health assessment has been performed within the last 12 months, it is not necessary to repeat the health assessment under certain conditions. The new receiving screening must be reviewed to determine whether there has been any change in health status. If there are no changes, the review and the decision to not repeat the assessment must be documented in the health record. Otherwise, when appropriate, histories, physical examinations and tests should be updated on readmitted individuals.

A word of caution for facilities that include the mental health screening and oral screening in the initial health assessment: If the health assessment is deferred at readmission and there are no changes in health status, the mental health screening and oral screening still must be completed with each admission. Failure to perform those screenings may result in compliance issues in other standards.

An Integral Component of Health Care

The intent of the health assessment standard is that qualified health care professionals identify a patient’s health needs and establish a plan for meeting those needs. Having a process to effectively and efficiently complete health assessments is an integral component of a correctional health care system.