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gemeeflE
U * Correctional Service Service correctionnel Canada Canada
Medical and Services Health Care médicaux et Services de santé
Health Care Record Dossier médical User's Manual Guide de l'utilisateur
CanadU
SECURITY - CLASSIFICATION - DE SÉCURITÉ
OUR FILE - N / REFERENCE
1718-1
YOUR FILE - V / REFERENCE
DATE L 1985.03.07
lietLen/
D. Craigen
UIBRAR Y MINilsTRY OF TH g: eoaztog C, Fm7RAt.
5c■ iqqç
eituponAtQuE henskeettE
Géseaz
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Attach.(6)
• Government Gouvernement of Canada du Canada MEMORANDUM NOTE DE SERVICE
r- e. ALL HOLDERS OF THE MEDICAL SERVICES
HEALTH CARE RECORD USER ' S MANUAL L_
FROM Director General, DE M2dical & Health Care Services
SUBJECT OBJET
•
AMENDMENT #2 - HEALTH CARE RECORD USE ' S MANUAL
Instructions and examples demonstrating the use of the Narcotics and Controlled Drug Sheet (CSC-794) are attached.
Please insert these.amendments after the Patient Médication Record in Section III and replace the Table of Contents with the updated version ' supplied. Effective 85.04.01, this form will be available from CSC printing plants.
Because all dispensary records can be maintained on one sheet, perpetual inventory control will be simplified. Thus, use of the Narcotic and Controlled Drug Sheet should be initiated as soon as possible.
• GC 177 7540-21-798-8998
SECURITY - CLASSIFICATION - DE SÉCURITÉ
OUR FILE - N / REFERENCE
1718-1 YOUR FILE - V / REFERENCE
DATE 1984-09-28
I+ Government Gouvernement of Canada du Canada MEMORANDUM NOTE DE SERVICE
All Holders of the Medical Services
TO eÀ Health Care Record User's Manual
L_ r- Director General
Medical and Health Care Services FROM The Correctional Service of Canada
DE Ottawa, Ontario
SUBJECT OBJET AMENDMENT LIST #1 - HEALTH CARE RECORD USER'S MANUAL
1. The manual enclosed, dated March, 1984, combines new information with that previously covered in the May 1980 edition of the Health Care Record User's Manual. As the 1984 manual fully replaces the 1980 manual, it is requested that the 1980 edition be destroyed and that users familiarize themselves with the new Health Care Record User's Manual.
2. Major changes occur in the presentation of the instructiohar content:
o Flow Charts have been removed.
o Information has been consolidated with redundant material discarded.
o An Index and revised Glossary are now included.
A condensed instructional design for individual health care forms is introduced, which allows manual users to identify at a glance, specific areas of a form requiring explanation. A page numbering system for each Division and Section allows pages to be inserted into or removed from the Manual without major revisions. Page numbers for each Division are preceded by the number of the Division, e.g. I-4 (Division I - page 4). Division III which includes 6 Sections, has each Section numbered separately. The number of the section is in brackets,' followed - by the page number for that section, e.g. 111(4)-2, ( Division III (Section 4) - page 2 of Section 4 ) .
A few minutes spent examining the TABLE OF CONTENTS will make the page numbering system for this manual obvious.
.../2
GC 177 7540-21-798-8998
2
o Index tabs indicating the 6 sections of the manual's Division III, are cOlour-coded to correspond to the various shades of the colour (at the bottom of each form) identifying forms file-d-f-digéther in one of the 6 Sections of the INSTITUTIONAL HEALTH CARE,RECORD
. 9 ACTIVE FOLDER (CSC 403).
o The POMR system, introduced in the 1980 Manial, is éiPanded upon within the instructional content for the INSTITUYIÔNAL HEALTH CARE RECORD, ACTIVE FOLDER (CSC 403) and many of the inaïvidal health
-- care forms. Emphasis is placed on the MAJOR- PROBLEM- LIST (CSC 57) -and its use as a concise reference and index- a.id for the Health _
--Care team.
3. --- The INSTITUTIONAL HEALTH CARE RECORD, ACTIVE FOLDER . (ESE -41M-and the - PATIENT MEDICATION RECORD (CSC 55) appear in a revised format. -Toms _
----- --new to this Manual are:
INPATIENT CASE HISTORY (CSC 571)
-- REQUEST FOR MEDICAL SERVICES (CSC 377)
-- PATIENT AUTHORIZATION TO DISCLOSE PERSONAL HEALTH rel INFORMATIOW _ 666)
This Manual will continue to undergo revisions and améneets.' Manual uses are encouraged to forward comments for inclusiOn in this process.
. Gnien D.P.M., M.R.C.Psych.
DATE INSERTED AMENDMENT NO. SIGNATURE
o /, •
fr et
A Li (
RECORD OF AMENDMENTS •
•
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• i(L CvY (ec-1-: s L/1
•
•
HEALTH CARE RECORD USER'S MANUAL
FOR
MEDICAL AND HEALTH CARE SERVICES BRANCH
OF
THE CORRECTIONAL SERVICE OF CANADA
PUBLISHED UNDER THE AUTHORITY OF THE COMMISSIONER
ISSUED BY:
DIRECTOR GENERAL, MEDICAL AND HEALTH CARE SERVICES BRANCH
REVISED: SEPTEMBER 1984
11 `I ■crioR
%5 OlricQ JE
7111 SI Si ..1‘ 1111 1.1r c Ï.UK
PREFAU
•
This edition of the Health Care Record Users Manual has been designed to
provide up-to-date direction on the use of health care forms constituting the
CSC Institutional Health Care Record. It also includes currently "in use"
instruction on the collection of requested statistical data from the health
care recording system.
The continuous up-grading and standardization of CSC health care
documentation is based originally on an analysis of a Methods and Procedures
study conducted at Edmonton Institution, and on an on-going basis from input
by field staff with overall direction and implementation by the Medical and
Health Care Services Branch, the Correctional Service of Canada (MHCS, CSC).
The current format of the manual has been developed to accommodate and expand
with this process and as such will allow new information to be inserted
without revision of the entire manual. The overall content of the manual and
the relevance of its format will, however, be reviewed and revised on a
regular basis. It is hoped that CSC Health Care Personnel will provide MHCS,
NHQ staff with commentary for future consideration in this process.
A Glossary of Terms and Abbreviations, and an Index are new additions to
this edition as is a condensed instructional design for individual forms.
This new format will allow quicker and easier access to required information
on a reference basis.
Among the content changes included are some necessary to ensure
compliance with the American "Commission on Accreditation for Correction".
The Health Care Record Users manual is intended to be used as a companion
to the Policy and Procedures Manual for the Medical and Health Care Services,
CSC. Individually the manuals address different aspects of the same topics
and so compliment one another in terms of the overall information they
provi de.
OTTAWA September 1984
D. Craigen, M.B.Ch.B., D.P.M., M.R.C. Psych. Director General Medical and Health Care Services
• ca • >1. ▪ co —II-m m —I. C3
.'.71
•
- 11 -
-TABLE OF CONTENTS
PAGE
PREFACE
GLOSSARY OF TERMS AND ABBREVIATIONS iv
DIVISION I - INTRODUCTION I-1
1.1 Purposes of the Health Care Record I-1 1.2 The Problem-Oriented Medical Record System I-1 1.3 Management Responsibilities I-3
DIVISION II - HEALTH CARE RECORDS MANAGEMENT II-1
2.1 The Health Care Record - Definition II-1 2.2 The CSC Health Care Record
- Institutional or Psychiatric - Active or Inactive - Current or Dormant II-1
2.3 Storage of Records II-2 2.4 Transfer of Health Care Records and Recall of
Dormant Records II-2 2.5 Rules of Record Keeping II-4
DIVISION III - INSTITUTIONAL HEALTH CARE RECORDS - ORGANIZATION AND USE OF FOLDERS AND MEDICAL FORMS III-1
3.1 Organization of the Institutional Health Care Record III-1 3.2 Sections of the Institutional Health Care
Record Active Folder 111-4
3.2.1 SECTION 1 III(1)-1 Major Problem List (CSC 57) III(1)-2 Medical History (CSC 416) III(1)-4 General Physical Examination (CSC 61) III(1)-7 Record of Immunization (CSC 378) III(1)-10 Dental Record (CSC 133) III(1)-12
3.2.2 SECTION 2 III(2)-1 Doctor's Orders and Progress Notes (CSC 471) 111(2)-2 Treatment Record (CSC 469) 111(2)-4
3.2.3 SECTION 3 III(3)-1 Patient Medication Record (CSC 55) 111(3)-2 Narcotic and Controlled Drug Record (CSC 794) II1(3)-5
3.2.4 SECTION 4 III(4)-1 Consultation Report (CSC 56) 111(4)-2
3.2.5 SECTION 5 111(5)-1 Laboratory Report Record (CSC 49) 111(5)-2' Radiography Requisition and Report (CSC 51) 111(5)-4 •
PAGE
3.2.6 SECTION 6 III(6)-1 Admission/Reception Medical Procedures (CSC 418) 111(6)-2 Inpatient Case History (CSC 571) 111(6)-4 Request for Medical Services (CSC 552) 111(6)-8 Administrative Summary (CSC 377) III(6)-11 Patient Authorization to Disclose Personal Health Care Information (CSC 666) 111(6)-13
DIVISION IV - COLLECTION OF STATISTICAL DATA FROM THE INSTITUTIONAL HEALTH CARE RECORDING SYSTEM IV- 1
4.1 Admissions and Discharges Sheet (CSC 484) IV-1 4.2 Health Care Centre Activities Report (CSC 30) IV-8
ANNEXES
A Health Care Records Management Checklist A-1 Institutions Eligible to Receive and Store Health Care Records B-1 Procurement of Forms and Other Supplies C-1
D Routine Medical and Health Care Information Required by Administration - A Reference Chart D-1
INDEX Index-1
•
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1•••• •
C/3 SIN
■QC
•
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The following Glossary has been sub-divided into 2 parts:
PART A: Terms and Abbreviations Specific to CSC, Health Care Services.
PART B: Suggested Medical Terms and Abbreviations for use in CSC, HCS, Health Care Recording.
•
•
GLOSSARY OF TERMS AND ABBREVIATIONS
PART A - TERMS AND ABBREVIATIONS SPECIFIC TO CSC, HCS
Alias: Name an inmate may make use of other than his/her legally-recorded
given name.
Active Folder: A blue jacket (CSC 403) which contains, in 6 filing sections,
information necessary to support and document diagnostic procedures and con-
tinuity of treatment.
Attending Physician: Physician responsible for the overall management of an
individual inmate/patient's health care.
Current Record: All health care records pertaining to an inmate under custody
of CSC. These records may be filed in an active or Inactive folder.
Dissociation: Segregation, separation or isolation from the General
Population for the maintenance of good order and discipline of the
institution.
Dormant Records: Health Care Records of an inmate no longer under custody of
CSC. These records are stored initially at the local level and eventually at
Public Archives.
Elective Surgery: Procedures that are advantageous to the patient but not
urgent, including cosmetic surgery to improve or restore normal appearances.
FFI: Free From Infection and Infestation. Refers to part of the Preliminary
Reception examination. •
FPS Number: Finger Printing System Number. This number is assigned at
initial incarceration at a CSC institution. It remains the same irregardless
of the number of transfers or re-incarcerations.
• General Population: That group of inmates who commonly inhabit an institu-
tion. It does not include those hospitalized, in dissociation or on parole.
Health Care: The sum of all action taken, preventive and therapeutic, in pro-
viding for the physical and mental well-being of an individual. Health care
includes medical and dental services, mental health services, nursing,
personal hygiene, dietary services, and environmental conditions.
Health Care Personnel: Individuals whose primary duties are to provide health
services to inmates in keeping with their respective levels of health care
training or experience.
Health Care Team: That group of Health Care Personnel who by their interac-
tion and combined expertise provide quality health care.
ICD: International Classification of Diseases. A classification of diseases
may be defined as a system of categories to which morbid entities are assigned
according to established criteria. It provides a common basis of classifica-
tion for general statistical use. Reference: Manual of the International
Statistical Classification of Diseases, Injuries, and Causes of Death; Vol. 1
- 1975 Revision, World Health Organization, 1977.
ID: Identification.
Inactive Folder: A standard manilla folder used to store "spill over" docu-
mentation which need not be maintained in the active folder due either to its
nature or currency.
Inmate: A person who, having been sentenced or committed to penitentiary, has
been received and accepted at a penitentiary pursuant to the sentence or
committal and has not been lawfully discharged there from.
•
•
• Inmate Number: That number assigned an inmate on admission to an
institution. An inmate is assigne& a new number when transferred from one
region to another.
•
Inmate/Patient: Term used to identify an inmate receiving health care through
CSC, HCS.
Institutional Health Care Record: Pertains to that documentation of an
inmate's health care while under custody of CSC. It may bè stored in an
active and inactive folder and be current (filed in a CSC, HCC) or dormant
(stored at the local level or Public Archives upon the inmate's release). It
is used within institutional HCCs and medical wings of Regional Psychiatric/
Treatment Centres (RPC/RTCs).
Medical Examination: Is an investigation carried out by a Physician which
includes a comprehensive, problem-oriented history and a physical examination
resulting in an assessment of the state of health of the individual and.
diagnosis of any problems.
O&A: Organization and Administration. Possible storage area for Health Care
Records of released inmates.
Paroled Inmates: Persons to whom authority has been granted to be at large
during their term of imprisonment under "mandatory supervision".
Pill Parade: Terminology referring to the dispensing of medication to
inmate/patients at pre-determined times on an out-patient basis.
POMR: Problem-Oriented Medical Record.
Physician's Parade: The assessment of inmate/patients by a Physician at a
pre-determined appointment and on an out-patient basis.
•
Pre-Medical Examination: Is an investigation carried out by a Nurse which
includes a detailed medical and dental history, physical measurements,
audio-visual testing, and obtaining blood and urine samples for analysis. In
addition to the appropriate nursing skills, those medical techniques of
inspection, palpation and percussion sanctioned by the provincial/territorial
nursing authority, shall be used in this systematic examination.
Psychiatric Centre Record: Records used only within Regional Psychiatric
Centres.
RPC/RTC: Regional Psychiatric/Treatment Centre.
Screening: Refers to initial assessment of an inmate/patient in order to
determine his/her health care status and subsequent ability to enter the
general population.
SOAP: Refers to elements of problem-solving for POMR. Subjective data,
Objective data, Assessment and Plan details.
Warrant Expiry Date: Date of end of sentence.
Young Offender: The new "Young Offenders Act",1982, deals with young persons
between the ages of 12 and 18 who have been charged with specific offences
against the Criminal Code and other federal statutes and regulations.
•
- viii -
41, PART B: SUGGESTED MEDICAL TERMS AND ABBREVIATIONS
FOR USE IN CSC, HCC, HEALTH CARE RECORDING
at
a.c before meals
ad lib as desired
ADL Activities of Daily Living
(eating, bathing, toileting, dressing, etc.)
amp ampoule
approx approximately
aq. ad. water up to
b.i d twice a day
B.M Bowel Movement
BMR Basal Metabolism Rate
B.P Blood Pressure
B.P C British Pharmacopoeia Codex
B.R P Bathroom Privileges
• BSP Bromosulphalein Excretion
BUN Blood Urea Nitrogen
° C Degrees Celsius •
controlled drug -
Ca Cancer
-c-; cum with
CBC Complete Blood Count
cc. cubic centimetre(s)
CF Canadian Formulary
cg. centrigram
cm. centimetre(s)
CNS Central Nervous System
C.O.L.D.;C.0 P D Chronic Obstructive Lung Disease; Chronic
Obstructive Pulmonary Disease
CPS Compendium of Pharmaceuticals and Specialties
C & S Culture and Sensitivity
C.S F Cerebrospinal Fluid •
- ix -
D.A T Diet as Tolerated
D.C.; Diff. Differential Count
deg degree
disc.; d/c discontinued
doz dozen
ea. each
ECG; EKG Electrocardiogram
E.0 T Enteric Coated Tablet
ECT Electroconvulsive Therapy
EEG Electroencephalogram
(E)ENT (Eye), Ear, Nose and Throat
ER Emergency Room
ESR; SR Erythrocyte Sedimentation Rate; Sedimentation Rate
et and
Ext Extract
F.B Foreign Body
fl. fluid
fort strong
ft. foot (feet)
g.; G.; gm Gram(s)
gr. grains
G.I Gastrointestinal
gtt drop(s)
G.U. Genitourinary
gYn gynecological
Hgb Hemoglobin
h.s at bedtime
ht. height
I.0 U Intensive Care Unit
I.M Intramuscularly
I. and O. Intake and Output
I.P P B Intermittent Positive Pressure Breathing
I.0 International Unit
I.V Intravenously
IVP Intravenous Pyelogram •
- x -
gll, kg. kilogram
KUB Kidney, Ureter and Bladder
1 litre
L;ICD lt Left
lat lateral
liq liquid
L.L L Left Lower Lobe
L.L Q Left Lower Quadrant
L.0 L Left Upper Lobe
L.0 Q Left Upper Quadrant
M. Molar
m. metre
max maximum
mcg.; g. microgram
mEq. milliequivalent
mg. milligram
min. minimum; minute(s)
mIU MilliInternational Unit
• ml. millilitre
mm. millimetre
Narcotic
N. Normal •
N/G Nasogastric
neb. nebula, spray
neg. negative
NF National Formulary (U.S.A.)
No. Number
nocte (at) night
N R Do Not Repeat
NPN Nonprotein Nitrogen
N.P 0 Nothing By Mouth
N.S.(S) Normal Saline (Solution)
•
- xi -
0.0 B Out of Bed
0.B Occult Blood
obs. Obstetrica l 0.0.; q.d every day (note: daily should be written out to
avoid confusion with right eye o.d. and q.i.d.)
o.d. ; eye right eye ( R eye preferred abbrev.) OP(D) Out Patient (Department)
OR Operating Room
o. s. eye left eye (0 eye preferred abbrev.) OT Occupational Therapy
0 U both eyes (use "both eyes")
p c after meals
PERLA Pupils Equal and Reacting to Light Accommodation
PH measurement of hydrogen ion concentration
(acid-base status)
Physio Physiotherapy
p.o.; per os by mouth
POMR Problem-Oriented Medical Record
pos. positive
post posterior
prn when (as) required
pro for
pt patient
pulv powder(ed)
q.a m every morning
q.d.; 0. 0 every day (see note for 0.D.)
qlh every hour
q2h, q3h (etc) every 2 hours, every 3 hours, (etc.)
q.hs every night
q.i d four times daily
q.2 d every other or alternate days
q.s a sufficient quantity
•
•
- xii -
gl, R,G, rt Right
R.B C
Red Blood Cells
rep. repeat
R.L L Right Lower Lobe
R.L Q Right Lower Quadrant
R.0 L Right Upper Lobe
R.0 Q Right Upper Quadrant
Rx take (prescribed drug or treatment)
S.0 Subcutaneously
S.G Specific Gravity
SGOT Serum Glutamic Oxaloacetic Transminase
sig. label/as "label" a prescription
7> without
S.0 A P Subjective, Objective, Assessment, Plan
S 0 B Short Of Breath
spec specification, specimen
SR; ESR Sedimentation Rate; Erythrocyte Sedimentation Rate
one-half
gib stat. at once
std standard
supp. suppository
syr syrup
tab tablet
TB Tuberculosis
temp. temperature
t.i d three times daily
Tinct.; Tr. Tincture
TPR Temperature, Pulse and Respiration
ung ointment
URI Upper Respiratory Tract Infection
USP United States Pharmacopeia
UTI Urinary Tract Infection
•
- xiii -
Venereal Disease Research Laboratory
Vital Signs
volume in volume
White Blood Cell Count
weight
weight in volume
weight in weight
fracture
percent
increase, raise
decrease, lower
female
male
to, toward
greater than
less than
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1=1 .1= C13
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DIVISION I - INTRODUCTION
This division introduces the PROBLEM-ORIENTED MEDICAL RECORD SYSTEM used by:
MEDICAL AND HEALTH CARE SERVICES BRANCH, THE CORRECTIONAL SERVICE OF CANADA
An outline of management and operational responsibilities is also included.
1.1 Purposes of the Health Care Record
Health Care Records are initiated for a variety of purposes. Primarily,
they serve as a basis for planning, for continuity of patient care, and as a
means of communication among the health care providers contributing to that
care. Health Care Records provide documentary evidence of the course of the
patient's illness and treatment and serve as a basis for review, study,and
evaluation of patient care.
There are secondary uses as well. Health Care Records ensure that data
for health care facilities management, program evaluation, research and educa-
tion will be provided. They also assist in protecting the legal interests of
the patient, the Correctional Service of Canada and the health care staff.
Many approaches to Health Care documentation exist. The one adapted by
the Medical and Health Care Services Branch of The Correctional Service of
Canada (MHCS, CSC), is based on the Problem-Oriented Medical Record system.
1.2 The Problem-Oriented Medical Record System
The CSC Institutional Health Care Record's organization and format is
based in part on Dr. L. Weed's "Problem-Oriented Medical Record" (POMR)
system for documentation. Forms within the record can be used in all phases
of the health care process.
•
• There are four basic elements that must be incorporated into a records
system in order to satisfy the POMR basics:
I. Establishment of a data base ii. A formulation of all problems - the problem list iii. Plans for each problem iv. Follow-up on each problem
As well, the POMR system requires a logical structuring of information at
the onset of a problem in order that basic information requirements are met.
Notes on a problem must contain at least the following elements (The SOAP
technique):
Subjective data - (Stated Problem) -Objective data - (Symptoms) Tssessment - (Diagnosis) Plan details
In terms of the CSC, Health ...- Care Record, this information
is recorded on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
Subjective Data
All subjective information including "symptomatic" data, i.e. what
the patient feels is the problem. This "symptomatic" data is to
have priority within the problem notes.
Objective Data
What is observed by the health care provider, i.e. Physical find-
ings, etc.
Assessment
Your assessment of the symptoms and observations, plus previous his-
tory of the patient.
Plan .........
Diagnostic, therapeutic, patient education plans, etc. The proposed
treatment plan for the patient.
•
All information once gathered is charted on the Doctor's Orders and
Progress Notes (CSC 471) as illustrated by the following example. •
•
•
I - 3
S - Patient states he has feelings of worthlessness and hopeless-
ness. Patient complaining of inability to sleep and eat.
0 - Appears pale, exhausted, withdrawn and sad.
A - May be suffering from depression.
P - To be seen by Physician - placed on special observation. Check
eating and sleeping patterns. Encourage patient self-esteem
and decision-making. Develop one-to-one relationship.
1.3. Management Responsibilities
Authority and responsibility for the Health Care Records system is divi-
ded in the following way.
Director General, Medical Services (DGMS) in consultation with departmen-
tal records management authorities, must ensure that policies, standards
and procedures are reviewed at least annually; that policies are complied
with; that records operations and management systems are continually
evaluated; and that state-of-the-art practices are maintained.
The Director Information Access and Records Management (NHQ) is responsi-
ble for advising DGMS on those aspects which affect the Health Care
Record and for assisting DGMS in the development and implementation of
general policy standards and procedures related to health care records
management.
The Director, Preventive Security (NHQ) is responsible for advising DGMS on those aspects of security of information which affect the Health Care
Record and for assisting DGMS in the development and implementation of
general policy standards and procedures related to health care records.
RHQ medical and health care staff provide functional support to the
Deputy Commissioner and monitor compliance with policy and procedures.
•
Assistant Wardens (Health Care Services) and Senior Health Care
Officers are responsible for day-to-day management of Institutional
Health Care Records in accordance with approved policy and procedures.
Institutional administrative staff are responsible for the management of
the Institutional Health Care Record during its dormant phase. Responsi-
bility for the day-to-day custody, storage and onward transmittal
in accordance with departmental, and medical and health care services
policies and procedures is normally assumed by institutional administra-
tive staff unless other arrangements have been made with local medical
authorities.
•
•
•
•
0 .1= CI,
0 = ..... •
s
•
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FI - 1
DIVISION II - HEALTH CARE RECORDS MANAGEMENT
This division provides an overview of the components of the CSC Health Care Record, its movement within the system, its storage and eventual disposition. Guidelines for the standardization of record-keeping in Medical and Health Care Services, CSC are included.
2.1 The Health Care Record - Definition
Every health care agency develops a system for recording and preserving
the records of health assessment and care provided for its clients. The con-
tents of the client's chart or record will vary with the purpose of the agency
and with the number and kinds of health professionals involved in the client's
care.
2.2 The CSC Health Care Record - Institutional or Psychiatric - Active or Inactive - Current or Dormant
Inpatient, outpatient and/or special services for an inmate/patient are
recorded in his/her CSC Health Care Record. This record may have two basic
components:
i. The Institutional Health Care Record - used within institutional
HCCs and Medical Wings of Regional Psychiatric/Treatment Centres
(RPC/RTC).
ii. The Psychiatric Centre Record - used only within RPC/RTCs.
When an inmate is received into an institution, the inmate's name is
entered on the current record register, an Institutional Health Care Record is
prepared and it is stored in the current file. The current Institutional
Health Care Record record consists of two folders: an active folder containing
information necessary to support and document diagnostic procedures and conti-
nuity of treatment or services; and an inactive folder which consists' of
"spill over" documentation which need not be maintained in the active folder
due either to its nature (e.g. copies of accident and injury reports) or its
currency.
II - 2
The current (active and inactive) Institutional Health Care Record
becomes dormant when an inmate is no longer under custody of CSC. The
policies contained in the DI on Health Care Records Management (DI 700-1-07.1)
allow for a variety of administrative arrangements to exist at the local level
with respect to dormant Institutional Health Care Records. There are however,
basic rules of record-keeping and storage which must be applied uniformly.
These points are expanded upon in sub-divisions 2.3, 2.4 and 2.5.
2.3 Storage of Records
There are several regulations governing the storage of Health Care
Records. This is in accordance with storage criteria for confidential public
records (CD & DI 700-1-07.1). In order to facilitate access and to decrease
the possibility of mis-routing, current Institutional Health Care Records
shall at all times be stored apart from all other inmate records and located
within the physical confines of the institutional HCC or RPC Medical Wing.
Active records shall be stored in a separate location from inactive records to
permit rapid access. Health care staff shall control physical access to
current health care record storage areas and filing cabinets. Records shall
be filed in a systematic way, and a register listing all current records shall
be maintained by health care staff. (The current register.shall be updated on
a monthly basis).
2.4 Transfer of Health Care Records and Recall of Dormant Records
The current Institutional Health Care Record, which is created on the
initial reception of the inmate, moves with that individual through CSC to
eligible institutions. An eligible institution is one which employs full-
time, part-time or contracted health care staff (a list of eligible institu-
tions is found in Annex B).
If the inmate is transferred to an institution which is not eligible to
receive his/her Health Care Record, an Administrative Summary (CSC 377) is
prepared and sent to Administration at the receiving institution. (If trans-
ferred to an ineligible institution served by a Health Care Centre in a nearby
institution, the inmate's record is sent to the servicing institution).
•
•
•
•
II - 3
When the inmate is released from an institution his/her Health Care
Record is sealed, marked "Medical Confidential, To Be Opened By Medical and
Health Care Staff Only" and sent, where possible, to O&A for storage. These
dormant records should be marked with the inmate's name, FPS number and
warrant expiry date.
On admission to an RPC/RTC, required information is transferred from
the inmate/patient's Institutional Health Care Record to his/her RPC/RTC
Record. The Institutional Health Care Record is then stored in the RPC/RTC
Medical Wing in order that new treatments and other medical information can be
recorded while the inmate/patient is at the RPC/RTC.
Upon an inmate/patient's transfer or discharge from an RPC/RTC, all
records are reviewed and necessary transfer/discharge summaries are comple-
ted. Copies are placed on his/her RPC/RTC Record and Institutional Health
Care Record. If the inmate/patient is transferred to an institution eligible
to receive health care records, his/her Institutional Health Care Record is
transferred to that institution while his/her RPC/RTC Record remains in
dormant storage (RPC/RTCs are the only CSC institutions authorized to receive
and hold RPC/RTC records).
Storage of dormant records takes place at the. institution or RPC/RTC and
eventually at Public Archives. Institutional or RPC/RTC Health Care Record
storage currently extends to one year after the inmate's warrant expiry date;
records are then transferred to Public Archives for long . term storage. If an
offender re-enters the system at some future date, dormant records can be
recalled. Records may ultimately be destroyed as outlined in DI 700-1-07.1.
If the inmate comes back into the system at another institution before
his/her records have been transferred to Public Archives, the receiving insti-
tution creates a temporary Health Care Record and requests the dormant record
from the institution last responsible for providing health care. When the
record has been located, shipped and received, it is amalgamated with the tem-
porary record. A request to retrieve a dormant Health Care Record from Public
Archives must be processed through the Information Access and Records Manage-
ment Directorate at NHQ.
II - 4
2.5 Rules of Record-Keeping
All information requested in authorized health care forms shall be pro-
vided and entered according to the following rules of record-keeping:
• All entries shall be made as soon as possible after the event takes
place.
• The entry shall be made by the person directly involved with the
patient.
• All information in the Health Care Record shall be recorded and
maintained in chronological order.
• Each entry shall be signed in such a manner that the identity and
the qualifications of the recorder can be quickly determined.
• Corrections shall be made only when there has been an error in
recording, not an error of decision. Errors are not to be erased
but merely stroked out and signed. The error must remain legible.
• All entries in the record shall be in ink or typewritten. In order
to maintain the credibility of an entry, the recorder must not
change pens during a single entry.
• All information shall be recorded consecutively without allowing
blank spaces or lines.
• Non-medical data which is not essential.to patient case management
(e.g. inmate offence data) shall be omitted.
• Unauthorized forms shall not be used except where an authorized form
does not exist.
The contents of the CSC Institutional Health Care Record shall be
organized or re-organized only in a prescribed manner as outlined in
Division III of this manual.
• Offender interaction with any member of the health care team shall
be recorded and include the nature and time of the event as well as
the action taken by health care staff.
•
•
• ee mic Co
cm = — —
•
•
•
III - 1
DIVISION III - INSTITUTIONAL HEALTH CARE RECORDS - ORGANIZATION AND USE OF FOLDERS AND MEDICAL FORMS
This division covers the instructional detail required to initiate the set up of an inmate/patient's Institutional Health Care Record and the subsequent recording of information on specific medical forms. Sections 1 through 6 correspond to the sections found in the Active Folder of the Institutional Health Care Record and as such contain the information pertinent to each form in that section.
3.1 Organization of the Institutional Health Care Record
The CSC Institutional Health Care Record is a collection of standardized
forms documenting the health care provided for each inmate/patient. The over-
all organization of the Record and format for the forms it employs are based
on the Problem-Oriented Medical Record system as outlined in Division I of
this manual.
The various forms, described in the following sections 1-6, are
employed only as needed. As such they comprise the current Institutional
Health Care Record described in Division II of this manual.
The individual forms, once completed, may be filed in the Inactive or
Active folder of the current Institutional Health Care Record.
1. Inactive Folder
(contains "spill over" or outdated documentation)
- a standard 8i X 14" manilla folder marked "Medical Confiden-
tial" and identified with the patients' name, number and Finger
Print System (FPS) number is used.
2. Active Folder (CSC 403)
(contains information necessary to support and document diagnostic
procedures and continuity of treatment)
- a heavyweight pressboard blue jacket with two built-in dividers
and two-inch capacity Acco fasteners is used. This allows for
six filing sections with a total maximum expansion capacity of
three inches (reduced copy of front and back of folder
follows).
ATTENTION
SE MAJOR PROIELFJA UST
VOA USTE DES RROBLEMES
MAJEURS
PREFF_RRED OFFS:1AL LANGUAGE LANGUE DE CNOIX OFFIMA1 I A
ENOUSH - ANCILNS
FRANÇNS - FRENCH
YOUNG OFFENDER vEs CASE UI
CAS DE JEUNE ENO CONTRE VENANT(E) NoN
May indicate availability of
I Young Offender medical records •
Affix Red Avery
.lsticker (See Annex C) to
, indicate 1, problems listed
on the MAJOR PROBLEM LIST (CSC 57) which may require special consideration. (See also page III (1 )-2)
r---
îl 3 e
î g
L _1
=1
- -
See Annex C page C-5 CD
Lru-u
17=
(=")
=
CIESICC 403 0.4 84-031 _
MI OIR 1.1.1M 1[L rumiup imurrm. rr1
111-2
âlr_tU EMI (iiU rnrYll) _
PERSONAL INFORMATION SANK BANQUE DE RENSEMINEMENTS PERSONNELS
CSC - P-40 SCC - P-40
HEALTH CARE SOINS DE SANTÉ
4
e 28
Cavectiorm Samos Saw. ccencuornei Came Canaan
• The Young Offender's Act which became law in Oct/83, permits CSC to obtain inforrnation concerning young offenders, who have been transferred from provincial jurisdiction to a Federal Institution. It does not, however, authorize the disclosure of such information to outside agencies.
To ensure that this information is protected from unauthorized disclosure, a formal procedure of record identification has been adopted. All file jackets of young offenders are now annotated to alert users and holders 01 records.
•
•
q_uni?,111)
Received' Returned
Date reçu,
retourné
aMal
FILE CONTROL — CONTRÔLE DU DOSSIER —1111,MIM
Transferred/ Referred to
Remarks
Transferred
InitiaIs /Referred Date
Transfère ,remis à Observations Initiates
' Record all Inmates ,
Patient transfers
transfère remis
Use for notations on file control as required (e.g. access to file by non-medical personnel). Reference 01700-1-07.2.
See Annex C: Tab Compu-Color numeric labels, page C-1
2 a
—
5 •
. e7
- -
IO W !
III — 3
E=E
ŒE
==9
E)== ftn-9
.CE)
FO
R N
HO
US
E O
NLY
-
RÉ
SER
VÉ
À L
'AD
MIN
ISTR
AT
ION
CE
NT
RA
LE
SEU
LE
ME
NT
o• M
111
0
.• < c 0
C 7 < z P P
Laii,m1 ?null 1L 1E]W
III - 4
3.2 Sections of the Institutional Health Care Record Active Folder
The remainder of this division has been subdivided into sections I
through 6 which correspond to the sections of the actual Institutional Health
Care Record Active Folder. Each section contains samples of the applicable
forms and a description of each form under the following headings:
Form Title and Form Number: - self-explanatory.
Purpose: - intent or role of form.
References: - where applicable, indicates the relevant
cross reference to the Commissioner's Direc-
tive, Divisional Instruction, Medical and
Health Care Services Policy and Procedures
Manual or Division's of this manual (Health
Care Record User's Manual).
•
• Interrelated Forms:
Copies and Distribution:
Procedures:
- lists forms which provide input to, or require
output from, form described.
- indicates number of copies (this includes the
original) and final disposition of each copy.
- provides condensed sample of form with ins-
tructions on use of form in the health care
process.
•
09 ea C) .—..
fas■ = —.
III(1) - 1
SECTION 1 OF THE ACTIVE INSTITUTIONAL HEALTH CARE RECORD
• Contents:
Major Problem List (CSC 133)
Medical History (CSC 416)
General Physical Examination (CSC 61)
Record of Immunization (CSC 478)
Dental Record (CSC 133)
•
•c.
•
III(1) - 2
MAJOR PROBLEM LIST FORM NO. CSC 57 11,
PURPOSE: To serve as a reference or index of all major health pro-
blems for an inmate/patient from initial reception to
release. A major health problem is defined as a major
health "concern" which has been identified by the patient,
or member(s) of the health care team.
To indicate major health problems as identified by the
patient or health care team member(s) that are active,
inactive or resolved, and to denote their onset and/or
duration.
REFERENCES: Policy and Procedures Manual 105.1
FORMS INTERRELATED: Doctor's Orders and Progress Notes (CSC 471)
Medical History (CSC 416)
General Physical Examination (CSC 61)
Consultation Reports (CSC 56)
Radiography Requisition and Report (CSC 51)
Laboratory Report (CSC 49)
COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record. (Section 1)
PROCEDURES: See form sample.
NOTE: This form must always remain as the top form in Sec-
tion 1 of the Institutional Health Care Record. It provi-
des quick identification of potential emergency medical
and/or psychiatric conditions e.g. allergies, metabolic
disorders, severe depression, etc); and indicates to the
health care team those chronic conditions which must always
be addressed with each new medical intervention (e.g.
diabetes). It is essential that this form be kept up to
date.
•
•
Correctional Service Service correctionnei Canada Canada
MAJOR PROBLEPA LISTE MAJEUR LIST DE PROBLÈMES
MEDICAL CONFIDENTIAL
MEDICAL CONE IDENTIEL
IN 00 IIrn NO
NO du airottlein•
1 1 State problem briefly and concisely.
•
•
Ill (1 ) - 3
• I. %Noel lotormoodon Om* Nomkom 23241
PMI iota bonmuo fèdeMI do donNII«
Innmnes no0M Nan du datonu
Inman% number PROMO° do dOtonu
numboi
!Windt° S.E.D.
INSTITUTION ÈTABLISSEMENT
Record inmate/patient ID data.
Date Oration, No.
idlotod lo 0( onset 04004
v.^ IM-1A I 0-J
1/1110IIVO Or unolvo0
Non 1004411f OU earl
Y•A lu- M I D-J
Date roeotelto
Rotation se« Dot• •nroçusiri
It no Ou oroblOnito y«, 1 I 0.1
Prooéon15— Proownwn
Number sequentially in order of entry on list.
4 11111 1
Enter date when determined.
LA 1
L_I 1
1
I 1 1_L
1 1 1 1 I
1 1 1 1 1
Refers to problem(s) previously listed to which problem in ques-tion has reference to.
1 L_1
L_I
1 LI
Ui 1
L_1
LA 1
L_I
L_1
1 LI
L_1
LA
1
1__I
CSC 57000. SMO — PEN 1057
L_1 MAJOR PROBLEM LIST
1 LISTE MAJEUR DE PROBLÈMES
III(1) - 4
• MEDICAL HISTORY FORM NO. CSC 416
PURPOSE: To provide initial health care data for future reference.
To initiate the identification of problems requiring health
care intervention.
REFERENCES: Commissioner's Directive 700-3-06
Divisional Instructions 700-1-07.1, 700-2-15, 700-3-06.1.
Policy and Procedures Manual Table 201, Procedure 200,
202, 303.3, 403.
FORMS INTERRELATED: General Physicial Examination (CSC 61)
Radiography Requisition and Report (CSC 51)
Dental Records (CSC 133)
Doctor's Orders and Progress Notes (CSC 471)
Major Problems List (CSC 57)
COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record. (Section 1)
PROCEDURES: See form sample.
•
•
This form is initiated when a new inmate enters the institution. All items requested on the form must be
I examined and all positive findings must be detailea in the proper section
'Record inmate'patient 'ID data • PS. Neese..
Num.* OC 0
Infneere nurnaere
eluoulro eleeenu
Oete .4 0000.
Den Oe noemoove
Yoe •■ • ■■ .9■1
• 1 1 • Il
1
E ii
30. Ceoro,tos
Cleo>. / Gloom
••••• tenors° / Tao. • oer••
Record drug, mode of use, dosage and frequency, date and or
time of last use, plus history of problems since ceasing use e.g. convulsion.
Inmate patient is to 'sign • MeMleaf• Seonatur• oe Yeolenou
III (1) - 5
• CO, reCTIOnal SerieCt SefV102 00 00 001, onnei Canait Canaoa
MEDICAL ANTECEDENTS HISTORY MEDICAUX
le Flame IMesesNalen Sam No..
le 000 Imam 111111rwe .11 • lear••••• 23241
Inonine none
Noun Ou Neon,.
MEDICAL 511410ICAL
CO*1910INTIAL CONE IDENTIEL
1,42717,.)71014->
2, 0e-1512.2NT
'0 OD DE COMPLETED SY THE INDIVIDUAL - 4 REPOPLIA PaA LE P•TtEse
PE•SONAL HISTORY . - - 4 - ...ea. now. of 1(0R (00 110? one 0 , the 10111.en,
ANTECEDENTS PERSONNELS - 6eanlua.1 cum 'or - 1,6 v000t aua. ONO 104■ 461.4 0:1000.08 «seem am mamas mowers,
5.10. MOP of conCuaa.On
3.11 111.9..,•• 'caves • o• re. ou cower...on airdrome*
tnmate'patient has been hospitalized for
mental disorder or suicide attempt pro-vide detail
2.D fabeeosyAm exmcJoulme• 210.00011/evanOulaffenentl LE lbeentat •Ndereere. ntro0,0 eeeeleadoe,
INIv0,001611e. 061enamons reeroeum
5ye grocer. conectem lonta• o. mow trOUOM
" E 91 111. noteuent1 • a et tee ffetueent1 6deu•noeuent neeelocneo Ear. NO or inf.? dome.
Aflee,.on reee ore... Ou net ou ele pf10
Lune Oteeele 0•Innte. Offluolent Couen , U0of • ,,,K1.0ns eminsonmfoà. dielnfne rou• tenoo, turmoulow
C,S:71,4, :ifin n aNasee.o.106 efo00 11.0.6■00.11.0fIneso
Of Drown e061•014. OU COMU. nypertene.04, olbouflenuent
11. DChronlc conellt.on, , Ooctiona cO.onfouoa <to
0.60.611 0 , N.•ney, •180•00/ of ...It,. œroont. mono. lete40.6.olee nelne. 064 6,10.11 ou Me Oftenee fenneu 6 . 12. D
rneurnaltorn. •neurna1. teeof AeInflt•. Mulnotiorne teen» fnuenar.ffneet
• E Yee eein. filneteurfs oleo. .• OelOnne WRI104/0.
6,11eopee. nee •euer Of Oh« Axerem. Neves On 40Inb. 40(tèClelr0 Is. Venom.. On..
1./164010 v0056000.
-
à•SWER TNE OOL4-0.904,3 CIIJES', 10190- 91
10. ""1. '""n".: * 101cnro"niou 'es'
17C T, 050 es aiersIts ,1•400l0( O. ,excen.c. 0. octagons - Sto.•44 es Domed. lin? 0. 0(0(101.01 0111600001
Ou Ou row 17A E d•m•
001 Aux QuESTION3 IVAMTICS
Vele/Oul
D 19.
21. vuse you cue 10r..9, aes awsressens cease...we
20. Moe you ewer peon •rnIttee to no.po•l , A606-0ous 060 too un Mour t • 601 110
41 %Mum - Q,e4a •
Ci mane - OU
ci On,y\-\-•
• D 1 22. vase yOu one no•Ulef •Befctoo ocnooulo , Faneovous rélueOreenent to romrcio• onrmoue
23. N•ce reu be., 0,1,00 ...Pun Deft 12 fnontns' ewed.frous eq. oolio9.....• oeno•nt .64. 12 Om rnon , Indicate dates , if
possible , of past immunization E ".
24 ••••• vot/, &nu on vp, phy.t.i
ocIteite eaelle noltre ■ nte •
CONEUNIPTION / DEPENDENCY - 04 row 001 500 Ot <no fouo.u.ne menu•,
USAGE i DEPENDANCE - Foètee-vout un usage oo'
26...beee'Peotene. foamy. Odooél.ty Denman cd CprINBergy,., 1. 1 e1U/00,1110 tO ■OC. une telenten erworenOlt• une .n0010,10,
Refers to therapeutic I medication
33_ Asuesol / Axes.
Neer /111.•9
/ Son
RaNIUNIZATi011e- con. 'cud 404 .1.›.11=1:1ron tot tne toll000.ne'
um maimter$0418 f 19 ..111 •111.11 ■••11•11 .
ZS Tetenu• / ',Moos \
29. ,.•••,...•••• RIO / bobeer.u1010
M. boo
Si 11 Inhumes. (1,u) ; Inn 10.0.1
32 Deohroeno / 04 1Pot•Yee
Refers to Molt drugs
IA 04 / 0 .-
Limit to immediate relatives Discriminate between blood
relatives and others
AA0g, y HtS70111Y ro" on, e you. 91000 m.o.« sumo.. o. 50101 4 emovelil elect• ANTECEDENTS FAMILIAUX 3•Nea0lsu0• ■••• - X - s.■ sus m.o. sweets • csaià iced fen ae - Saesers ....nu «tents
to=1.ao ceoleir•r• 3'11;1 »mars Ou coourfnyoergenyen, flee.« ...peewee«. we." as•••••ftuen wee. Oresiou. rheeeendetle 0030l Da•onos
MeoOl•
Sintufe 12.01.60.y) Att.. 0 • 66/00.••• (EtMooe1
42 r-1 r_ -
I If inmate'patient is un- To lei coespLerto my muggy - o1/4narLin PAM L'INFIRMENE
'cooperative. note NI 0011.11.• fInenee - Con% ef 111111.11 NM eon.« or...«
fono.ty ienet• iteseatrall Selbetto. eg10.1mta0o0ts)
Nurse is to date and ' sign (specify
qualifications) as recorder and witness i to inmate patient's signature
NOmoore tarot.« Jmormoon correct ••■•■olu. mem ob. Ye...moon elm •ucte
Comma. o• - Coonoodel ode Ouse
50(5.- v A seas 0 2
1_1 Gluaufx.ebons
C./C/SCC Olt 10•. 11/121
4 NOTE: Inmate/patient should NOT be showered before being examined for FFI.
Soin Reeser Meteionne Perm Puble Area
16-14 D-J
E..] No Plo
DouVee, Mob patient elpean free from Innalout es contelligul endue La Datlent oaraltilisre elnleCtion au 60 50111010 contadieume
If no — ILlehoeee49141.nnet ace le Ca
44. Heins Tallie
45. Weldnt Colds
I. Ptilee Ret• — Pools 47. Morro Pretitire Tension •rteeteile
Slel.111/0
411.Tentip. Cotelue
Yes Osn
52. Urinalysis — Anon»
Blond Send
enton PrOtent
57. Mantoux
Results Inv') Roluttats (met/
•
•
III (1) —6
TOUE COMPLETED BY NURSE (Viable rreemmendeved — A REMPLIR PAR L'INFIRMIÉRE (Memo« mivmum)
• 43. F.9.1.. Tn• loilosain4 oen folerniniedli
V
/71
Len Vinsectiono A4lione sunninlin ont M. exam/Mee
need 741•
Examination must be conducted on every new inmate/Patient-(FFI examinations resulting from a Tem-porary Absence are noted in DOCTOR'S ORDERS AND PRO-GRESS NOTES (CSC 416).
Mouth lbouCne
Date
9. Closet Expansion — Develoarner.t
FIJI, I nosiration Exteraston Oranm Insolmtlen 1 Ettoiretton Inc lone
50. VISUAL ACUITY — PERCEPTION VISUELLE 31
Uncorrectea Corrected
Sent con-action Au. tenet:Ion
RIgnI Dean
1.611 Glaucis•
Determine each item accurately and record in metric.
O Oast« L1.111111I.
Canteen 1..ent111« oarneennes
Color Simone« E:11 Sperev color affected: o titoNente
Oftener la mule,
Il the results are abnor-mally high, repeat at rest after 20 minutes or at end of examina-tion and enter results in Section 2 of Box 47.
Elaborate — Examples: dentures (upper); ar-tificial eye (left) etc.
D 11111e D ekle
CSC — Corn III Moon Count CC5 — atomisation glicoulene
lEemnm 00.40151 00 sang)
VORL — Venereal Onuses Renaten Lab. LRLIu — ROCIlerChe SU , NS rnaladoet
vénértennes
53. Meertnot ConversatIonat voice 6 50 Permotton etptilUm. ton sle conversation norrnele, 56m.
Lett Normal Gluon. Morena.
gre:
55. nsostrieses
—› ern:: lil (Incluans 60001111
Present Vol Present Oui
Fill in appropriate distance in metric for which the inmate/pa-tient has an apparent disability.
54. Blood tamales nn1 Can/million <nun, •nvoyé 56. Chest erRov Plealoorattnie Puirnentare
Yes Our
Initials — Initiates
Elaborete on Ill gentle, Inning, Commenter les cons ttttt Iont anormales
Cle t e: Da le :
been
Storatur• and Qualhintions / 51enatur• Cluellimations
Major Problems identified, are noted on the MAJOR PROBLEM LIST (CSC 57), and processed using the "SOAP" technique, on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
III(1) - 7
GENERAL PHYSICAL EXAMINATION FORM NO. CSC 61
PURPOSE:
REFERENCES:
To record a diseae or condition requiring medical atten-
tion in the interests of the inmate/patient or the institu-
tion population.
To record the physical and mental status of the inmate/
patient in terms of fitness for normal institutional acti-
vities and against which his/her health progress may be
assessed.
Commissioner's Directive 700-3-06
Divisional Instructions 700-1-07.1, 700-3-06.1
Policy and Procedures Manual Table 201, Procedure 202,
208.4, 400
Standards for Adult Correctional Institutions, 2nd Edition,
1981, American Correctional Association 2-4289, 2-4290.
gl, FORMS INTERRELATED: Medical History * (CSC 61)
Doctor's Orders and Progress Notes (CSC 471)
Major Problem List V (CSC 57)
- Patient Medication Record (CSC 55)
Treatment Record (CSC 469)
* Physician to review before starting physical examination
COPIES AND DISTRIBUTION: ONE - Remains on Institutional Health Care Record (Section
1) whether inmate transferred or released.
PROCEDURES: See form sample.
NOTE: A physical examination of each new inmate is carried out and recorded by the Institutional Physician, with assistance from the Nurse, within seven days of initial reception into and before final release from a CSC facility. Dates of physical examinations are to be transcribed to section divider 1 of the active folder (CSC 403). •
III (1 ) — 8
All items requested on the form must be examined and all abnormalities noted in the appropriate check box. Any abnormality checked must be detailed in the appropriate narrative section. If all findings are normal , indicate so in the square provided.
I 4p i, i irri• I"vIit `,,,, i 1,rkr i. Lorlik Iirtnntti Federel Irdenenetion Bonk Number
C tcrid.1., No de I. tangos tiderato de donne« 23241
GENERAL RAPPORT Prima. t n•rne
PHYSICAL D'EXAMEN Horn du denenu
EXAMINATION MÉDICAL Inmate's number
MEDICAL MEDICAL Nurnero du DatenU
*- CONFIDENTIAL CONFIDENTIEL
F.P S. number To be ERIG•1•1•• MI Merecen - A renter per le neidoem Homer° 5.E.I7
Note only Manama/ finch.* Noter lele etteldstallona aneleenelall Imulammu
I GENERAL/ENDOCRINE/LYMPHATIC GENERAL/ENDOCRINE/LYMPHATIOUE ALL
INSTITUTION ÉTABLISSEMENT
›
APPEARANCE - APPARENCE Detail - Détail
02 General - Generei
0.1 Colo.,' - Couleur
04 Anemia - Anernee
05 Motnn - L• boucne
06 Teetn - Les dents —
07 Neck - Le cou
08 Thytoid - Le thymic:le
09. Lymph glands teermeel. Molla. suoreelencularl - Les ganglions
Lerblanataluet leervIcal, emIlmre tUdraClaNICulerel
10 8 'ems - Let lent
11 Up./ lobbl. n•nds and tempers - . Mentor, tutteneures mans et ddigIf
17 Spinal Column - Colonne vertebrale
13 Lower extiernities ieet and Teen -
Membres intérieurs pleat et veines
14 Scut - ClcalroceS
15 Skin Iliac.. - Enderrne ten/lotion/ [NOMA -re tr NO A•NORMAL FINDING INDIQUER Si LES CONCLUSIONS SONT NORMAL II
ii. CARDIOVASCULAR Detaii - Détail LE SYSTEME CARDIOVASCULAIRE
20 BM000ressuie Tension artenede
21 Pulse Irate end ertedUid -
Pouts If recuence et rytnrnel
22 Perceteral pulses - Pouls periphendue
23 Apex omit - Choc tustohque
24 Heart Sound - Le. bruits du erteur .
25 Murrnurt Bement, - Murmure 1p-relent) INDICATE IF NO A•NoRMAL ris DISC INDNaUlele Si LES CONCLUSIONS SONT NORMAL C
III RESPIRATORY SYSTEM Detail - Détail SYSTEME RESPIRATOIRE
30 Trachea - Trecciée
31 Chest rnavernent - Mouvement de la poitrine
32 Percussion - La percustion
33 Air entry - Entree de l'air
34 Adventin• - AcnentIce te/DICATE IF No A•NoRMAL FINDING INDIC:MLR SI LES coNCLUSIOlgS SON/ NORMAL
re GASTRO INTESTINAL/GENITO URINARY Detail - Detail CASTRO INTESTINAL/GENITO URINAIRE
PALPATATiON
40 lime - Le lore
41 Spleen - La rate 42 Kioneyt - Les reins
43 External penile. - Let organe 01111111■14 «tern«
44 Anus-An s
45 Rectum - Le rectum 46 Inwonal repion - La neen Inguinale
47 Ly,pM1 Wends - Les ganglion, lymPnenairet
48 Hernia - Merme
49 Ptritutt gland - Glmioe oe le prostate INDICATE IF 50 A•NORmAL FINDING
INDIDuER Si LES CONCLUsloNS SONT NoRmAL 1111
v MUSCULO/SKELETAL Detail - Détail MUSCLE/SOUELETTE
50 General - General
51 Umber limbs - Ley mernones adder/mu"
02 Lower Limbs - Les mernbrat intérieurs
53 Spinal colurrIn - La colonne vertilbree INOICATZ IF No A•NORmAL 'IMO..
INDIOLJEW SI LES cONCLuStONS SONT NORMAL II.
Record inmate/patient ID data.
•
•
PhVacren s legneure - Simmer,' ou rnIptetn Sr Pnvacient name («Intl - Non. du ',moved, (lettres moult«)
4/ Physician reviews the Health Care Record , notes new findings in the discharge summary section. and signs the discharge summary.
O.Sot emrn 011t de Pitmen«,
Year Month [My Anneel Mon Jour
85 PnYsicren s name lorintl - Nom du mloescnILItttITS mouiinl
Dale of exert Oate 6e S'exernen
Yoe Monti. Dav Anne* Mon Jour
Physicians SISSISture - SIgnillute Cu rnedecus
90 Oncnarge summery t to be COmeleted On Ocvlielen - Resumer:le renvore IA recnole aser le rnerSeern1
Ill (1) — 9
Ab Detad - Détail vr SPECIAL SENSES/CNS
60 Eyes lecturer pup. , acu ■ ly vift.1
Pupille
movproent• rtenni.
lonn Or , 0:1 ■41ift! peteptiOn
chaos Dee,
61 Es' sinci drum cane heerrner Les um icanainvmoans perceptron MVO
62 Noie - Le ne•
63 Throat - La gorge
64 Tongue - La tengue
65 Clam« nerves - Netts cramens
66 UtsPer extremity Iscreadv lelt OF 119011
Extrernot supeneure Ispecrfier gaucce au dro
67 Sensory - Les organes sensorsels
66 Motor fin« «ern°. - La fonction locomotive (tremble e Isr
69 Reflex« - Ref. es
TRUNK - TRONC
70 STIISOIT - Les rages« senso tir
71 Motor - La fonction locomotive
72 Lower extremrty (SPeCtly left or right) Estrernite onfeceure ISpICIllet «mane ou droner
73 Seniors- Les organes sansorren
SENS PARTICULIERS FONCTION SPECIALE/SNC
74 Motor Ilncl trernori - fonction locomotive (tremblements1
75 Reflex« final reenter mite I - Reflexes 1nel premed
76 G•It/Ficirnberg - Le dernarche/Rornoerg
77 Muscular (ton, waringl - Musculatrettrennite. StrOPn el
INDICATE le NO A•NORMAL FINDING
11.101P1USI5 SI LISS cONCLUSIONS SONT NOMINAL.
vu IMPRESSIONS OF MENTAL HEALTH Detail - Détail IMPRESSION DE L'ÉTAT MENTAL
ao ..nect - L'Intelhgence
81 EmOtiOnil stabIlity - La stabilite frnotionnelle
82. Other - Autre
Provide information on past and present treatment or hospitalization for mental disturbance or suicidal history, if applicable.
No OSIVIOUS AIIINOWISALtTy AUCVN cARAcracc connects, EVIDENT
83 Diagnosis - Daqnostic Dragnostic coorng - Code d agnostichre • 64 Fitness steles - Et« de tinte
When completing the physical examination a diagnosis is to be made when applicable, and recorded.
In V0i, Opinion. ■ S SPP ■ i.Sn , mentenv eno ohyslcaily fit for normal instrtution ectrvr Ire no «ready runitatrons treiowl
0aerntvnu,ie candid« esty mentalement et pnvs ■ quernene cote a .cornon, les Merle «ogees oar Oinstitution isr non 1PéCItier res restrictions necessairesi
N OuY"
o Non El
Determine fitness status of inmate/pa-tient and indicate in your opinion as to whether he/she is fit for disposition to (a) the general population (b) the general population with prompt referral to the appropriate health care service or (c) referral to appropriate health care service on an emergency basis. Record any orders for treatment, medication, tests, activity restric-tions, etc on the DOCTOR's ORDERS AND PROGRESS NOTES (CSC 471).
• Major Problems identified are noted on the MAJOR PROBLEM LIST (CSC 57), and processed using the "SOAP" technique on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
III(1) - 10
RECORD OF IMMUNIZATION FORM NO. CSC 378 0 PURPOSE: Maintains a record of all immunizations and TB tests, and
results for a patient from initial reception to release.
REFERENCES: Policy and Procedures Manual 303.2
FORMS INTERRELATED: Doctor's Orders and Progress Notes (CSC 471)
COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record (Section 1)
PROCEDURES: See sample form.
•
•
If Correctional Service Service correctionnel Canada Canada
RECORD OF REGISTRE DES IMMUNIZATIONS IPAMUNISATIONS
MEDICAL automm. CONFIDENTIAL CONFIDENTIEL
TAIILE I — IMMUNIZATIONS TABLEAU 1 — WAIRUNISATION
FEDERAL INFORMATION PiumÉno OE LA IMNOUE F
ANK FRAMER ÉDÉRALE DE DONNÉES
Irmmoif nroo Nom du &Mono
Immeto't num., NumM.0 du 041(mo
FIrl$. number Numb., S.E.D.
Dam of birds DM. MI (mimeo..
Record inmate/patient ID data.
FPS numb« — Mimeo 0.E. 01 Innitution — Etiellmornorn
23241
Ill (1) — 11
•
Veer AmuOf
Montn Dey MOIS Jour
Dew Record injection site type and dosage. Sign and enter qualifications.
Piro TOP. Aeww Islinuiso. $ir OINIK111
04 Omer Mrs Mententemon shoo Slepures do v«OMIllur
1■1•1G
• Record date of test plus subsequent results and size of induration. Sign and enter qualifications.
TABLE II — n CONTROL PROGRAMME TABLEAU II —PROGRAMME DE LUTTE ANTITUSERCULE — FPO TESTS — ÉPREUVES A LA TUCERCULINE PURIFIES
%Mr. nNorloe ov eseversion Ds of Indurtion Poole rmetlf ou dwedu pritit TWIN do l'inrorlon
Dom Ymr Month Dey
Anna* Mou Jour Moor.
CSC/SCC 370 (Rm. 11/1121 RECORD OF IMM)NIZATIONS — REGISTRE DES MOMUNISATIONS
•
III(1) - 12
• DENTAL RECORD FORM NO. CSC 133
PURPOSE: To serve as the ihmate/patient's dental history and record
reference for use by health care professionals.
REFERENCES: Commissioner's Directive 700-3-06
Divisional Instructions 700-2-02, 700-3-06.1
Policy and Procedures Manual Table 201, Procedure 202.2,
202.4, 208.4, 402, 404
FORMS INTERRELATED: Medical History (CSC 416)
COPIES AND DISTRIBUTION: ONE - Filed in dental area and transferred to Institutional
Health Care Record, (Section 1) on inmate's release
PROCEDURES: See sample form.
•
51 0000 ■• , •
34 egi 31 et0
Si /2 11
36 Ce,
31 De. cr. ity•n”.euo.. •
■ Stognatu.• o.
I S4,48.•• a.
c,ntt mcal.on r ■ •••••• in
eE'Lçtl
3,
ker:
Irorn• rIN•er. roalre.
OW,. or OY•Oriro•. 00.14 o.Ortrà eh. et• Neel.
, Aluen , •• Café paurne
P•b•nt r•ont CON. unm
Record inmate/patient ID data.
This form is initiated when the inmate/patient is received into the institution and is filed in the dental clinic. Each inmate/patient will have a dental examination as soon as an appointment is available.
/
▪
04un...t.r lover. meveneurn Or ORO. 41.7
▪ Ité•er 'Awns. ve44. Go .yen•tienne OL,
3.
On °totem./
theateoel
to ■ Noo•y)
D•l•al.1/44,
6
It entornoot•
t.y•r Or OrtInto Or
O. PO•l•rhorl au Igor- uo d•ir rel.!
111.• —
Oo you nave I4N lave. II•thrn• o. 09, •,11,0
CtrOut co l•d• pe• cu 'rs C•e•Inenn en, d•ledUr• •nou opt• • •7 .... .
Ar• ser411.Y• to •ny p. , I.Cu ■ •• Yr..0 t. 1• 40 , 1" D., c• ■■ .. loc•• nt•
f4•.enuà pootwe • te•Unn eniore•ener,s •••ofren• *neun4ste • ■•,,
At• HOU Unalt *b. ea. gmeonent ce , I•••no oeup• orod7
.el •ouns. P•un mécertn ou • renee.rou• et•t•Jn ■ rnécloc•ne•n,• ,
S ■ p•••,,4o. 3.yrn•ture. Or. oerrrr...•
711. 2 DONDITION ON ADMICSION --eAT DES DENTS À L'ADENSSION
Indicate initial dental status as determined by examination and interpretation of Patient History Questionnaire.
I+ Cormettnnal Frrvoce Can.9.13
correetkees4 C.f.13
DENTAL FICHE RECORD DENTAIRE
ISEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
Ss 1 PATIENT HISTORY OUESTIONNAIISE — ANTÉCÉDENTS NÉDICADX
INSTITUTION
irAltISSIMENT Completed by inmate/patient during initial dental appointment.
23241 Infeertmlun Son. hyrnne. i• 4 erne.. 1•0•Illap en panne,
L. may. you eye. flea uny te• •oiroe‘ng on•c• Avrt•vuuà tléaà •odflpre Co•nre. ves tb
Maw you •v •• pt.,. • .ong a'le. Ît ▪ o/ en. , on.an ,
Une rowed, ..•ru•rf,on dn• rlen• Pnero•vent•• ■■ •• .••• nenottad.na• „
Ou Yon
leono‘• • • n•me
Morn de dernnu
Inerry••• number Idune•to in d•tenu
.P.S. number
limed S.E.O.
0.5 No
Our NO,, Noon 1.0oolo
CSC 173 A.. *no - LIN1140
III (1 ) — 13
•
OAT' IMMATURE DUCRIRTIOM 0E TM/TWAT - OESCRIPTION DES SOINS
3. CLINICAL NOTES — EXAIDEN
Dan MILARILI - NaSsau
23
24
25
18 25
27
28
INIENNATIONAl TOOTH IDINT1F1CATION STS/IM
SYSTEM( INIERN•TIONAL D'IDINTIFICATION DES DENTS
13
14
cfo
GENE.At NOTES
, enne•oc eve: necesc , ..0 KI•Clull. 0.80 and MOORMO .n onit Soer de- •••• ,note• 4•5 ..0
ftelemaurs ciréé4.4LES
Sn tens Ionnér Iet 0.111 Slit e•ol■ evià farnIel er ore•erets à 1.t...
Intloover T•fériwr den eeeee à utili.1 Is. Enter each examina-tion, irregardless if treatment performed.
Pmfont..11 CD1i
Pai..nt's tog., rerno•
46 38
). 4 DENTAL TREATMENT — SOINS DENTAIRES
III (1) — 14
NOTES ON USE Of PIAGneet
C•ouya ogler. - Oyfe.ne pen./
fle•lorminn - 0.0.n. end 1.1. t mime Oto• St elect • nk.
ixso4cuon 4..40 - X on pre° over tooln u•ncemen.
14 >song Ir•tn - lie•oeudoste• fon• Ineouen Veen, concern..
COMMIIT 114111114.11,1 LI 'TABLEAU SCHE-MATIOUF
Can...Menge •-■ trmaa Ile corn., No Cleo.
leegeyfetfone 'Meer contoto Si rnefewer I 14.4 ploy. ott no,4,
ExneChen• Reeser... - b... un a RA emeen sit In iMet Si. immimulie.
051ot• manEmEnnia - varier une 1,115 ennwe.olletelo Su/ 45 elento on ouottlton.
•
AU dental x-rays taken within the institution shall be af-fixed to the record.
1. DENTAL TREATMENT ICont•th — SOINS DENTAIRES
DATE DESCRIPTION Of TItATINN/ — DESCRiFTTON CIES SPINS SIONATUN
AFFIX ODEPRIE COATED TAPE ON INADED AREA
Moms AA. 71110-21-601.1 Mel
X-RAY
RAYON X
APPOSE* LA SANDE' ADNESIVE (ADHESIVES SUR LES DEUX SUAFACESI
SUR LA IMAM MARA Cif'
Ire de Ilmtereclaber• ESTO•21-881•IIII ■
OPEN END OF
MASTIC SAG
OUVERTURE Ou
SAC EN PLASEIOUE
If inmate/patient is transferred or released, his/her dental record is drawn from the dental file, a dental assessment is completed and documented and the record is inserted into Section 1 of the active file.
„../...e FIE tent•• npNI Ceti eau
INTERNATIONAL TOOT11 IDENTIFICATION SYSTEM
mime INTERNATIONAL D'IDENTIFICATION DES DENTS
REWARX. — REIIAROUES
411 38
47 37
Le 34 DIN• ei•saffnmon — Dote ee roomful+ Effective det • RI ream.— Oe.te S• lioennen
15
Z53 44 34 33
itsg 41 x1_1,2
of
Sfee uuuuu emuste
SIsneture elm..
ClIngc weaueon thnodir• de
FfuNg.• iett CONT pouffe •
III (1) — 1 5
•
s. cordornow ow RELEASE - ÉTAT DES DENTS À LA LIRERATION
•
• co) et.
II= = N3
•
•
III (2) - 1
SECTION 2 OF THE ACTIVE INSTITUTIONAL
HEALTH CARE RECORD
Contents:
Doctor ' s Orders and Progress Notes (CSC 471)
Treatment Record (CSC 469)
•
III(2) - 2
DOCTOR'S ORDERS AND PROGRESS NOTES FORM NO. CSC 471
PURPOSE: To record the progress of the inmate/patient's problems
using the SOAP technique.
To record all Physician's orders (written, verbal, oral,
standing) and his/her subsequent signature.
REFERENCES: Divisional Instruction 700-1-07.1
Policy and Procedures Manual 100.3
Health Care Record User's Manual - Division I (Problem-
Oriented Medical Record System)
•
FORMS INTERRELATED:
COPIES AND DISTRIBUTION:
PROCEDURES:
All Forms of the Institutional Health Care Record
ONE - Institutional Health Care Record - (Section 2)
See sample form.
Screening - Examine the inmate/patient and enter the iden-tifed problem on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471) and transcribe it on to the MAJOR PROBLEM LIST (CSC 57). Enter the problem number from the MAJOR PROBLEM LIST onto the DOCTOR'S ORDERS- AND PROGRESS NOTES as a cross-reference. The inmate/patient may be given standing order medication or treatment, and/or be referred to the Physician. Orders resulting from a Physician referral (e.g. laboratory testing, radiography, treatment, medica-tion etc.) are written on the DOCTOR'S ORDERS AND PROGRESS NOTES and processed according to the information provided in this manual for each individual corresponding form.
Note: In the event of an inmate injury, enter time of in-
mate/patient's arrival in HCC and time of subsequent treat-
ment(s) for that injury, plus date and time notation recor-
ded.
•
•
%Ion, Warman., tie* NI1Mbef
Nurniro a. lo boner» Meer*. do d.flelEm 23241
Record inmate/patient ID data.
loom. s norm Nom 0, «moo
moaner ro.e11. ■
Romero ou menu
P S. number NUT.> S E.D
t ■ • ■ • . 1,11.1 !!!!! •0101111, 1
Cd11,h1 ■ 1
DOCTOR'S ORDRE DU ORDERS AND MÉDECIN ET PROGRESS OBSERVATIONS NOTES SUR LE PROGRÈS (Problem (Oriente vers le
minted) problems)
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
1
o
• Record administered standing orders, STAT medication and single treatments after this vertical line.
Ill (2) — 3
• This form is for composite use by all health care professionali. It allows members of the Health Care Team to use a collaborative approach in alleviating presented health problems.
INSTITUTION ETABLiSSEMENT
Proorem. syroPtorn.thoErm.P.
Problernt. tyPPOIO ,PP. cOPIrnen Uwe
Owe
Y.A MM D.!
.elaon taken
Action Prue
Problem No
NO du 01001e nie
Enter problem number from MAJOR PROB-LEM LIST (CSC 57).
When recording a problem, enter comments using the SOAP technique.
Physician to enter written orders after this vertical line.
el9e2. 1/.4.4;4.... Nurse to initial when Physician's orders are processed.
Nurse to enter verbal, phone and standing orders after this vertical line. (Physician must countersign.)
1
• CSC 4 71 0..1,19801
DOCTOR'S ORDERS THIS SIDE ONLY ORDRES DU MÉDECIN DE CE CEITE.C1 SEULEMENT
NOTE: It is imperative that all entries be accurately documented in terms of date, metric time, and signature.
III(2) - 4
TREATMENT RECORD FORM NO. CSC 469 • PURPOSE: To maintain a record of ongoing treatment rendered to an
inmate/patient for a diagnosed problem.
REFERENCES: Divisional Instruction 700-1-07.1
FORMS INTERRELATED: Doctor's Orders and Progress Notes (CSC 471)
Major Problem List (CSC 57)
Consultation Report (CSC 56)
COPIES AND DISTRIBUTION: ONE - May be kept in treatment area . Upon completion of
treatment program, or when inmate/patient is transferred or
released, form is filed in the Institutional Health Care
Record (Section 2).
PROCEDURES: See sample form.
•
•
Service Servir COIUM100 ■ 10
Canna
TREATMENT FICHE DE RECORD TRAITEMENT
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
SC/SCC taati (R•v. 11/121 TREATMENT RECORD FICHE DE TRAITEMENT
III (2) - 5
Federal ledambeeten Rank Numb«
Nutmeg° cm la bomb» 11d4waie de donne«
Ifor• name Non, Cly a•t•nu
lobrneale nuriln•I
Nurneo do eeeee
Nurnow hornet, S I 0
Dom 01 Uath
D•t• ue naluanc•
23241
Record inmate/patient ID data.
INSTITUTION
ET ASLISSEMENT
Ptan.Oroel - Plm.lbrut
Tre•tments - T'anernent,
Order/plan transcribed from DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
Date v MM
I Do
P/00.71 no - N. du ummterne Enter problem number from MAJOR PROBLEM UST (CSC 57).
IflhI,.IS III 11.nS‘tor.,
11111. 14., Oo TronscNOt•or
LA
LA
I I
Record each treat-ment with date, time, comments and signature. Problems arising should be documented on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471) using .the SOAP technique.
• NOTE: Problems requiring a single treatment with no further plan of action should be recorded on the DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471). There is no requirement to initiate a treatment record for this type of problem.
Co., CD C, •■••■• .a..
= G4.
•
•
III(3) - 1
SECTION 3 OF THE ACTIVE INSTITUTIONAL
HEALTH CARE RECORD
Contents:
Patient Medication Record (CSC 55)
•
III(3) - 2
PATIENT MEDICATION RECORD FORM NO. CSC 55
PURPOSE: • To provide a comprehensive plan for the administration of
medication in accdrdance with the institutional Physician's
orders.
To record those medications issued to a patient which are
administered for a pre-determined period of time and at
pre-determined hours. It should also include PRN medica-
tion dispensed during pill parades.
REFERENCES: Divisional Instructions 700-1-07.1, 700-2-02
Policy and Procedures Manual 302.4
FORMS INTERRELATED: Doctor's Orders and Progress Notes (CSC 471)
Inpatient Case History (CSC 571)
Major Problem List (CSC 57)
(Check for drug allergies and/or intolerances.)
COPIES AND DISTRIBUTION:
• ONE - Maintained in dispensary, transferred to the Institu-
tional Health Care Record (Section 3) at the end of the
month.
PROCEDURES: See sample form.
NOTE: Prescriptions can not be active for more than 30
days without the Physician's review and authorization to
continue. When a prescription, for a continuing type of
medication is registered on the Patient Medication Record
(CSC 55), draw a red vertical line across the thirtieth
day. (For that Rx only.) This will be clearly visable and
will signify to the nurse administering the medication,
that a Physician's review is required.
•
III(3) - 3
STAT medication when given is recorded on the DOCTOR'S
ORDERS AND PROGRESS NOTES (CSC 471) or the "progress notes"
portion of the INPATIENT CASE HISTORY (CSC 571) during
hospitalization in .the HCC.
PRN medication is recorded on the PATIENT MEDICATION RECORD
(CSC 55) when it is dispensed at regular pill parades.
In those instances such as when the first dose of a PRN
drug is administered during a HCC visit, it is considered a
STAT medication and is recorded on the DOCTOR'S ORDERS AND
PROGRESS NOTES (CSC 471).
During hospitalization in a HCC, PRN medication is recorded
on the "progress notes" portion of the INPATIENT CASE
HISTORY (CSC 571).
•
1 4> 1 RECORD PATIENT MEDICATION FICHE DE MÉDICATION
DU PATIENT
CSC I SCC - P40
lemma s run»
Num du Menu
NURSE IDENTIFICATION BLOCK - CASE ()IDENTIFICATION DES INFIRMIERSDÉRES)
ad. le at Duna. glans
Yoe° oollone enarel .441,
I..Doo Servir , ( Or 1.1 . ét1.1,d
Canada
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
Dena pred
MOM pawns
Transcribe from MAJOR PROBLEM LIST (CSC 57).
Pereonel Infonnellon Mani Number Nome() de I. banque de donneea perearmellee
Inmate's numbed
Numéçu toi del..,
Dona Make..
/anew, sal durebon tentwexe et .•tle
CSC (SCC 55 (Rm. 3181)
To be completed by each Nurse ad-ministering medication.
Dale of bed,
Clete de node..
INSTITUTION ÉTABLISSEMENT
_
FPS numbed
SE0
If not administered enter code and cir de e.g.(0
Order transcribed from DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
Pup ..01. arneldl
Frequenee end dueelan reednene el agree
ntale Gene d
Ole Wean.
22 23 24 25 28 27 31 28 I 29 30
Termination date
When reordered, enter date, new termination date, and continue to initial in same block'
Enter initials in box corresponding to day of month as each medication administered.
Defoe ...I
(We dadoorante
Dea Inno
laa nevelan
onarnenc•
De. Ma
ma. de maul..
Den. talon.
Dee
'01
Li Ir • NI J
de rue..
de ....um....
Deo• lea
Pea a ...anon
Dan ...eel
lade denannen.
Dar Won,
rare de gagman
. —
Due
• id D J
DJ
A Id D
— V • D I
I I
When prescription terminated, enter "DISC" on line and draw a red line through the balance of the boxes for that prescription.
As additional pages are re-quired, indicate page no and —
Record inmate/patient ID data.
lepancy and du*, f lot dun.
Dome Gae• dean.
Use 24 hour clock. If more than 4 "time" spaces are required, con-tinue in next block. Stroke out unused "Drug", "Dose" etc. areas.
• NOTE: For altered orders, stop order using "DISC" and register new order in new block.
• •
• PURPOSE:
111(3) - 5 - NARCOTIC AND CONTROLLED DRUG RECORD FORM NO. CSC 794
To record and control every dose administered to inmàtes of
those narcotics and controlled drugs specified by the
Narcotic Control Act and the Food and Drug Act, Part G.
Recording of other medications with a high abuse potential
is left to the discretion of the individual institution
after consultation with regional inspectors from the Bureau
of Dangerous Drugs.
To provide a perpetual inventory of medications with a high
abuse potential.
REFERENCES: Narcotic Control Act
Food and Drug Act, Part G
Policy and Procedure Manual 303.4.B.2 (new)
302.5.B (old)
• FORMS INTERRELATED: Patient Medication Record
Narcotic and Controlled Drug Register
COPIES AND DISTRIBUTION: One - maintained in dispensary
- transferred to the narcotic and controlled drug files
in the vault when sheet full
- filed in chronological order and retained for at
least two yeàrs.
PROCEDURES: See examples on sample form.
•
HI (3 ) - 5 - a
1. Quantity of each drug is transcribed from the preceding form and recorded -
here. If the User institution chooses not to record the administration of
optional drugs listed e.g. "282", "292", Tylenol #2, Tylenol #3, enter
zero in this space or cross-out the entire column as shown.
2. These columns are provided for "write-ins" i.e. medications used
periodically, other medications that require monitoring for legal reasons,
additional medications that the User wishes to monitor for security
reasons.
3. The signature of two health care professionals is required for partial
dose, breakage, and discard. The signature of the outgoing and incoming
nurse is required for shift audits.
4. Forms may be filed chronologically by date or number whichever is most
convenient for the User. Forms should not be filed until all entries are
complete and any discrepencies are clarified. Forms are to be retained
for at least two years.
5. Usage of the form is demonstrated on the sample form.
6. A record of the "write-in" that has been returned to bulk stock must be
continued until the sheet is filled and then dropped.
•
I. ■ cw..man is ....o. •moo ..ssn ■ rue ........—.....,-....
Canada Canada \......z...)
Personal Inlor &bon Class Cie Ida de ran moments personnels
NARCOTIC CONTROLLED REGISTRE DES STUPÉFIANTS ET Inshlution / Elabluieemenl DRUG RECORD DES DROGUES CONTRÔLES HEA QUARTERS
NOTE Foe instructions on completing NOTE Pour ramplir c• lormulalra e 1 this lone .14, to lea Hearth Care smaller consulter la 00.54., rbédiC111 Records Usat's Manure Outdo do l' unearthed
0 , c pr â8g -i-,8 e7g, ;;È,ÉÉ,
0 1 - ,, tq tf!. ',̂g; 1.0 ggl eP rrcci' NOTE: Tyro ores are return:I lor •
PAR DOSE - BREAKAGE - DISCARD
NOTE. Shift count and racarpts NOTE: Toulours Inscrire an rouge la
horn Mock elemys antared compte al las prodults reçus du E I ifr
t
'e lig H !l e lir W 8 t;
Ns can Is FITTELLE - .., E DOSE PA le red ink_ dace pendant la parboda de Inman. tÉ I l Q) 0
NOTE: Deux Kees nom rectums dans
BRIS ALI REBUT
Physician s name 8 et r
TIM• Inman* name FPS Number Iiirmil 8
Del. —
t... Nom du détanu %ruled S E D Nom du rnéclocn Iota StOCK Stock lode Nurse I Count Warless's Sbeakre (NM« mounds)
7X/X7.1, ' 25 25 2E 25 10 10 25 25 I fArtsôreIcOrttpI S 3stedotr0.
YAI IIA I DJ 25 m wasted 85 01 - 15 0820 L. Kitts 000007K D. Craiden 25 mc 9 -C./ • . VA 1 SI I D.)
85 01 15 1315 D. Sarazin 001001 11 D. Craigen n 23 .
Y•A I 14 I DJ r 4"'"--- ,1 , .7• /
85 01 15 1450 Returned to stock in vaul; (25 x Percodal) 0 1..,t...".../.--."-r..14.A....„.C , n_xœditA.c.„, Y•Al Id ID!
i.
8 1 1 1 50 ■ a: r.y64..t 5o 3 %Q Shç VA •A St I I) )
9 so o x e. eezuet .,!. 3;„ Y-A I li I D )
A VA I Id I- DJ
VALU IDJ
VA I 61 I DJ
VAI 1d I DJ
YA I Id I DJ
■ YA I bé I DJ
VA I IA I DJ
VA I Id I DJ
" I M I 0-j
Y•A &I I DJ
-------
• •
--,
CA er re ar re .11e.
•
•
•
III(4) - 1
SECTION 4 OF THE ACTIVE INSTITUTIONAL
HEALTH CARE RECORD • Contents:
Consultation Report (CSC 56)
•
III(4) - 2
CONSULTATION REPORT FORM NO. CSC 56
PURPOSE: To provide a health history summary of the inmate/patient
for the Consultant.
To provide a documentary record of the Consultant's find-
ings and recommendations.
REFERENCES: Divisional Instructions 700-1-07.1, 700-2-07
Policy and Procedures Manual 103.3
FORMS INTERRELATED: Medical History (CSC 416)
Doctor's Orders and Progress Notes (CSC 471)
Major Problem List (CSC 57)
General Physical Examination (CSC 61)
COPIES AND DISTRIBUTION: TWO Original - Institutional Health Care Record
(Section 4)
Yellow - Consultant retains
PROCEDURES: See sample form.
NOTE: Request that all medical information returned to the
institutional HCC be sealed in an envelope marked:
MEDICAL
CONFIDENTIAL TO BE OPENED
BY
MEDICAL AND HEALTH CARE
STAFF
ONLY
•
•
Cons ult ant s SIgneture — Signets. du médecin consultant InItiels of rehrnno prweiclen 'nibbles du médecin contultent
Date 0.1
Date ••■■ 1.1/8
NOTE: Duplicate form is forwarded (as pre-arranged) to the Consultant prior to, or with the inmate/patient for the appointment.
Consultant completes, retains duplicate , and returns original.
CSC 56 .EV. 0/60 — PEN 1054 CONSULTATION RAPPORT REPORT DU CONSULTANT
Ill (4) — 3
1+ Correctional Service Service correctionnel Canada Canada
CONSULTATION RAPPORT DE REPORT CONSULTATION
Feetei Infortnatean Bank Number Mo der la Calndue bedtime de donné
bums'. mime Nom 014 détenu
23241
Inmate'. number Numb.° du détenu
F.P.S. number Numéro S.E.D.
Record inmate/patient ID data.
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL.
INSTITUTION ÉTABLISSEMENT
Referred to — Refire é Dite Spicielny — Speeimisi Adams —
Physician identifies Consultant and com-pletes referral history.
Referrel nmory — Antecedents
Include date with signature.
%tiering poysielan — Spnutur. du MidIrtin commit:ant Con s u l tant s report — Remora du médecin consultent
Initial upon reading report. Enter problems identified by Consultant on MAJOR PROBLEM LIST (CSC 57) if applicable.
•
■
111(5) - 1
SECTION 5 OF THE ACTIVE INSTITUTIONAL
HEALTH CARE RECORD
Contents:
Laboratory Report Record (CSC 49)
Radiography Requisition and Report .... (CSC 51)
•
•
III(5) - 2
LABORATORY REPORT RECORD FORM NO. CSC 49
PURPOSE: To retain the inmate/patient's laboratory reports in a
chronological format for historical reference.
REFERENCES: Divisional Instructions 700-1-07.1, 700-3-06.1
Policy and Procedures Manual 103 - iii, 202, 207
FORMS INTERRELATED: Individual Laboratory Reports
Doctor's Orders and Progress Notes (CSC 471)
Major Problem List (CSC 57) COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record (Section 5)
PROCEDURES: See sample form.
Orders for laboratory testing are transferred from the
DOCTOR's ORDERS AND PROGRESS NOTES (CSC 471) to Laboratory
Requisition Forms. Standard CSC laboratory requisition
forms do no exist as most laboratorys prefer to supply
their own.
NOTE: Request that all medical information returned to the
institutional HCC be sealed in an envelope marked:
MEDICAL
CONFIDENTIAL
TO BE OPENED
BY
MEDICAL AND HEALTH CARE
STAFF
ONLY
•
•
• 7th — 7 1 .rn.
6Th — 6 1 5 11m e
_ 51erne
ad. - aierne
14th - 14ame
13th - 13ieme
12th -
111h- trierne
10th -
9th - 9 , ene
8th - 8. 4^14
3,d _ 3ierne
2ho- Vern.
14th - 14 1 eme
13th - 13 1.,•
121n - 12'e m e
111n - 11 1 e^,
10th -
9th - 9 , ern e
8th - 8 , e rne
7rn - 7 1 eme
61M1 - 6.rnne
5th -
eth - 4 1 eme
3ro - Verne
2ho- Veme
Attach laboratory reports in sequential order once reviewed by Physician. If ap-plicable, enter iden-tified problem(s) on MAJOR PROBLEM UST (CSC 57).
Attach 100 Of tut relSOft On Inn I.ne Fine le sommet du ra000, 1 Sur Ceti! • ahe
(5) —3
Correctional Service Service correctionnel LOP Canada Canaaa
LABORATORY FICHE DE RAPPORT REPORT RECORD DE LABORATOIRE
%tend Internortian Bank Number h. eta la bongoe ted4rMe de donee..
Innate t name Nom du détenu
23241
Innsetes number Nsinstro du deem,
F.P.S. number Nurreko 5.8.0.
ÉTABLISSEMENT INSTITUTION
REPORTS MUST BE ACCURATELY AND FIRMLY AFFIXED - BIEN PLACER LES RAPPORTS AUX ENOROITS INDIQUÉS
Record inmateipatient ID data.
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
LABORATORY FICHE DE RAPPORT CSC •9 111 04 4/80 - 0E14 soar REPORT RECORD DE LAIORATOtRE
•
III(5) - 4
RADIOGRAPHY REQUISITION AND REPORT FORM NO. CSC 51
PURPOSE: To provide pertinent medical information regarding the
inmate/patient to the Radiologist.
To document the radiological findings by the Radiologist.
To serve as documentation of radiological services render-
ed.
REFERENCE: Divisional Instructions 700-1-07.1, 700-3-06.1
Policy and Procedures Manual 205.5, 204.2, 406
FORMS INTERRELATED: Doctor's Orders and Progress Notes (CSC 471)
Major Problem List (CSC 57)
COPIES AND DISTRIBUTION: TWO Original - Institutional Health Care Record
(Section 5)
Yellow - Radiologist retains.
PROCEDURES: See sample form.
NOTE: Request that all medical information returned to the
institutional HCC be sealed in an envelope marked:
MEDICAL
CONFIDENTIAL
TO BE OPENED
BY
MEDICAL AND HEALTH CARE
STAFF
ONLY
•
•
Transcribe order from DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471).
Examination reouestea — Satan,. demande
RADIOGRAPHY DEMANDE DE REQUISITION RADIOGRAPHIE AND REPORT ET RAPPORT
Dote of reClUeSt Date de la de
EP.I_Pal-Pal 1:1
demande Signature of one...en Signature du medecin
I+ Corroott,Inal SPrVit
Canada,
SCrVICl• ‘Orrpitoloopl
Canant Federse Inf «Inman Bank Number N. da la bandol fiebieele â. donnees
23241
Inmate's rlarne Nom du detenu
fnmete's number Humor° du Oetenu Record inmate/patient
ID data. F P.S number Mertens S.E.D
MEDICAL CONFIDENTIAL
— MEDICAL CONFIDENTIEL
INSTITUTION ÉTABLISSEMENT
Completed by refering Physician. +Bate of odd, Yea Nero D.,
Date de naissance
Report to be tOrwafOIKI 10 — Adrener le rapport a
CI nell lormation ana diagnosis — Donnees coniques et diagnostic
If applicable, enter problems identified by the Radiologist on the MAJOR PROBLEM LIST (CSC 57).
Film No — N. du film Date of report Name of aleeltn Agency Signature of rebiologist Dete du rroort
Nees D
INITIALS OF RE FERRI G PHYSICIAN
Nam I a Nom de l'Agence de Santé Signature du radiologiste
i m-u i
› 1 DATE › '0 0,1
'INITIALES DU MÉDECIN CONSULTANT
DEMANDE DE RADIOGRAPHIE ET RAPPORT
Initialed and dated by referring Physician upon reading report and before filing.
CSC 51 Ree. and — .EN road RADIOGRAPHY RECIUISITION AND REPORT
Ill (5) — 5
Razioaloçail • S repeal — Rapport du radlologlite
4
•
Co, CD C1 a = crà
III(6) - 1
SECTION 6 OF THE ACTIVE INSTITUTIONAL
HEALTH CARE RECORD
Contents:
Admission/Reception Medical Procedures (CSC 418)
Inpatient Case History (CSC 571)
Request for Medical Services (CSC 552)
Administrative Summary (CSC 377)
Patient Authorization to Disclose
CSC Personal Health Care Information (CSC 666)
•
•
III(6) - 2
ADMISSION/RECEPTION MEDICAL PROCEDURES FORM NO. CSC 418
PURPOSE: This form may be used as a check-list aid in completing
tasks required for the initial reception of an inmate/
patient into a CSC institution.
REFERENCES:
FORMS INTERRELATED: Medical History (CSC 416)
Doctor's Orders and Progress Notes (CSC 471)
Dental Record (CSC 133)
Laboratory Report Record (CSC 49)
Radiography Requisition and Report (CSC 51)
Consultation Report (CSC 56)
COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record (Section 6)
Once all tasks are completed and documented on the corres-
ponding forms, this form may be destroyed.
PROCEDURES: See sample form.
NOTE: Maintain this form at the top of Section 6 in the
Institutional Health Care Record until all tasks are com-
pleted.
Feeler« Iblebbreben Uri Number %mere de Is berm. %Nob, de dambre
23241
Immune* nearn• Nom au ahem,
tnenalles number Numero du aris•nu
— Record inmate/patient ID data.
P.S Number Nurrusro 5 E D
Corr.cttonai ServIcr '
Canada CanaIa
ADMISSION/ PROCÉDURES
RECEPTION MÉDICALES
MEDICAL D'ADMISSION/
PROCEDURES RECEPTION
MEDICAL edÉolcat. CONFIDENTIAL CONFIDENTIEL
1+
keecne•t
AnteC ea len te enea re•u•
• Health Care Record forms and folder (CSC 403) prepared for use.
1 1
111 (6) — 3
•
Inritutrert
ÉteMimerrerrt
Chte Wren
Dem elan'. nerbutIon
Y•ts M.M D.J
Date Wren
Dam d'adrm• muumuu
Vt. MM
DM. reuerred
Der. 'Imo
4 MM
Degeripleoe Deeerrption
Urrn•lvms routine 1.100/B10,
Ex•rrien cles urmee Ilabor•sotr• ae rourmee
LJ L__1
,FFII Free From gntectron
a,teeston
L _ .aemetotoov - VD.,
erernatoiow• - FILMS.
1 I I I
Nut-amp ntssO , v
Resume am souls
HeernmorOo■ - CSC
Flernasolooi - ESE
I I I 1 C49. Mr31.1 , •04V
R.oro,rewue
1 I
'Memel exemm•sten
Ersamen
Denta. emorron•non
Exemen - dentsur•
Db11•1 slue.
Vérlficeslon des preoMouet
Orrensabon i.e. N•nabooe
OnentatIon ..e. Manuel
L
1
Flycnr•sr-C ••ern•netron
Examen osvcr-nerr,bu
esam.nel.on
Eeemen osecholop.oue
1 1 1
Only if ordered. Use I Consultation Report I (CSC 56).
Commend - Rellargle«
Use of HCC explained.
CSC.AII(brer•IMO) ADMISSION/RECEPTION MEDICAL PROCEDURES
PROCÉDURES — MÉDICALES D'ADMISSION/RECEPTION
•
III(6) - 4
INPATIENT CASE HISTORY FORM NO. CSC 571
PURPOSE: To record treatment and subsequent progress of an inmate/
patient while hosp.italized in the HCC.
REFERENCES: Divisional Instruction 700-1-07.1
Policy and Procedures Manual 301, 404 FORMS INTERRELATED: General Physical Examination (CSC 61)
Radiography Requisition and Report (CSC 51)
Major Problem List (CSC 57)
Consultation Report (CSC 56)
Laboratory Report Record (CSC 49)
Patient Medication Record (CSC 55)
Treatment Record (CSC 469)
COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record (Section 6)
PROCEDURES: See sample form.
NOTE: This form replaces the following forms:
Final Note (PEN 1115)
Record of Treatment Orders (PEN 1058)
Progress Notes (PEN 1167)
•
•
•
Ferlerbl Informenoe Bank Number N. de It donee. Fèderade de donee« -
lnrn•t• t name Non, 00 detenu
23241
Record inmate/patient 'I ID data.
Inrne• t nurnoe
Nurneo ou clean.
COrrearOnal Sarviœr Serviœ Wrrectiormul
Crovàcre Canar.l.
INPATIENT OBSERVATION CASE MEDICALE HISTORY DU MALADE HOSPITALISE
1+
De• ot o.rtn
Dale de neseenr•
Y.A At 04
P•fien , t ComfitIon an ddenerg•
Cana.fion malade atarI
D.tit de neseenr•
Ot, ,u1,onO,tnl
Mote Otl noarntelnenon
CHRONIC AFFECTIONS , CONDITION(S) CHRONIQUES
III (6) —5
This form is intitiated when an inmate/patient is admitted as an inpatient to the HCC. When completing the INPATIENT CASE HISTORY (CSC 571), all items must be completed as stated and information compiled during the course of the treatment.
MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL
FPS nurnoe
Nurnea S E D
ETABLISSEMI NT
Megnotit on edenttsion - Magnottic • l'admtitton
Adnfitean Ilea › V-A . ' i " M.na rd.... nfise
› Oete d adon I I Date ale tome
%cove. r-1 imoroved Not trnoroueo Guetto L. j Amend« D Pea otametorraton
1 Prootem No › I N. du oroblen•
•A Re 0.4
E 000.01.0
DIAGNOSTIC CODE
'CODE DIAGNOSTIQUE
From MAJOR PROB- I LEM LIST (CSC 57). l
On discharge frorn HCC.
Faun cfiagnofit - Magnum.. fine
Address unresolved problems and include statement of nmate/ patient's general condition on discharge. Transcribe unresolved problem(s) onto MAJOR PROBLEM UST (CSC 57).
Daeletans - In eeeee nfian cnuuro.• ■ •
S-mmer, 1Corna ■ ents ahem.' taboratOry anu • eav fintfingt etc I Sarnmetre tDoule.dt. can.ustant dea •umult.n ollyeaue leootatod• trelerne, •c /
Provisional diagnosis to be entered on admission as reference for Health Care Team.
On discharge from HCC.
Recornmenoàfiont - ftecornmenclefiont
4
Pneecien t name (P.m" - No!,, ou melee°, Ilettre. mouteetl
, Date Pnes..art's fignalur• - S ■ gneture 00 rnert«,n
V.A. N 0.1 1
1
CSC/SCC 571 (11/811
Transcribe from MAJOR PROBLEM LIST (CSC 57) on ad-mission as reference for Health Care Tean -i.
Transcribe into order(s) on DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471) if applicable.
NOTE: Upon discharge use DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471) for continuation of recording, if required.
•
- Examen medecar
IV.A M 13-.1 ob-ovS .C.AN S SIGNATURE
SoGNATuRE OU MEOECIN
REPORT OF OPEFIATION - RAPPORT DE L'INTERVENTION CHIRURGICAL
• Include time of day. 1
III (6) — 6
PHYSICAL EXAMINATION - EXAMEN MEDICAL
oilstone - Antleceo•nts
•
Complete during initial examination after admission. Enter other problems identified onto MAJOR PROBLEM LIST (CSC 57).
P.olroltOrdii - OteonoLloc orovosoir•
urea," I 10010 IP•.ntl - Nom ow CMIIY,110.1 Dames moulees/ I (Sete
V.A HI
Surgeon s segnantt• - S ■ anetur• ut. cno,,,en
•
PROGRESS NOTES 1Pr00nen sunned) — OSSERVATIONS SUR LE PROGRES h probhenn
Proo loot ActIon DATE No e1001M. vernotoen, ellooneoes troatrnont. comment. Dion
Prooieen• Moouroul P....en.. .......e,.. donnoSte. tootornoet. opornonterot
Y A . • nO Primly)
I" .4
• . ,
i lite .. s i ,,i-e /
L .
I 111
e
II
I I I •
I I
... . 9? - ..0,...Le.,... ._._._ __ •-_____ .
i
I I
Enter problem from MAJOR PROBLEM UST (CSC 57).
When recording a problem, enter comments using the SOAP technique.
Record administered standing orders, STAT medication and single treatrnents after this vertical line.
Nurse to enter verbal, phone and standing orders after this vertical line. (Physician must countersign.)
ims dt-
Physician to enter written orders after this vertical line.
Nurse to initial when Physician's orders are , processed.
III (6) — 7
This component of the INPATIENT CASE HISTORY (CSC 571) form is for composite use by all health care professionals. It allows members of the Health Care Team to use a collaborative approach in alleviating presented health problems resulting in admission to the HCC.
DOCTOR'S ORDERS ITHIS niumn anyl ORDRES DU NIEDECIN IC ETTE ogre ...Menem)
-a-
NOTE: It is imperative that all entries be accurately documented in terms of date, metric time , and signature. • •
FORMS INTERRELATED:
COPIES AND DISTRIBUTION:
111(6) - 8
REQUEST FOR MEDICAL SERVICES FORM NO. CSC 552
PURPOSE: To document the request and approval for elective and non-
elective-surgery, treatment and/or diagnostic services in
facilities outside CSC.
REFERENCES: Policy and Procedures Manual 103.3, 103.4
Divisional Instructions 700-2-07, 700-2-12
All forms of the Institutional Health Care Record.
TWO - for non-elective treatment or elective treatment
under $3,000.00.
THREE - for elective treatment over $3,000.00
All copies are forwarded to the institutional Finance
Administrator and Warden for signatures of approval.
If the request for elective treatment is not approved at
the institutional level, one copy of the form is placed in
the Institutional Health Care Record (Section 6) and the
other(s) destroyed. •
If the request for elective treatment is approved at the
institutional level all signed copies are forwarded to the
Regional Manager, Health Care Services (RMHCS) together
with any copies of relevant medical information which may
assist with the decision making-process. When the request
is for elective treatment under $3,000.00 and it has been
reviewed at the regional level, both copies of the form are
signed; one is retained by the RMHCS; and the other is
returned for filing in Section 6 of the inmate/patient's
Institutional Health Care Record.
•
- 9
When the request for elective treatment is over
$3,000.00 and it has been reviewed by the RMHCS, all three
signed copies are forwarded to the Director General,
Medical and Health Care Services for review. One copy is
retained at NHQ, and two returned to the RMHCS, with one
filed in the inmate/patient's Institutional Health Care
Record.
PROCEDURES: See sample form.
NOTE: In the event a request for elective treatment is not
approved, the attending physician is responsible for infor-
ming the inmate/patient of the decision. The interview is
to be documented on the DOCTORS ORDERS AND PROGRESS NOTES
(CSC 471).
•
•
114e Correctional Service Service correctionnel Canada Canada
REOUEST FOR DEMANDE DE MEDICAL SERVICES SERVICES MÉDICAUX
Inrrtata .i *4 Den ou *Root,
Mcrae. number Nurrao du ram.
FPS Numb« Numéro S.E.O.
Ertimetest exceencliturtn — Faun.4 rlee deserrees
Nato lyertemmt , Tramernent à FnOolte
Olagnopic bustle« Sprats.. divan= issue
Surgiutirriecller le» F rails crilrurlietuarmedicaus
INSTITUTIONAL FINANCE ADMINISTRATOR — ADMINISTRATEUR OES SERVICES FINANCIERS DE L'ETABLISSEMENT
..n,tv ert funds ore toollabur in the • moroocoto oboe te toy for the obovo «mutts.
J. condo qua deg PM* lent theoniblos dons le Cott. concerné elm crolloctuot I. moment de resorni carat rotneonné.
INSTITUTIONAL DIRECTOR — ADMINISTRATEUR OE L'ETAILISSEMENT
Cornmenttiree SIgnelure
Dale
Y-A le4 D.!
Deciaion Oeeneon
c;) D Not •porossid
Nen lbOOf Duple
Almon.— Poison, Signature
FRIIIICS Doe *Rem tromorat) — ARES (pour Stanton.« famine/
Totootrat — Treiternent I Comments — Commentaires Signature
Completed for elective treatment requests only.
/ D Non ateineurett Not elerOved
D Amoco., ^op° yeé•
Date
Y-A 1.1 0.J
The Novo reondituro it WOrand and um:on« ooraco g honey motorized undo moon if memory.
L.. deem« caout Net Nterouvilos. et robottnct tonotorturo dit anomie tout mono Si nécomoiro.
DOMNCS — Dot Waive Immoral ow, 53,000.00) — OGSMSS (pout bottomed foothold Wog mc. $3.000.00
CSC/SCC 502 (Roo. II/13)
III (6) — 10
Form is initiated by completing this section.
Physician or Dentist enters case history in-formation and signature.
ottrao rumor* or Nohow —a oho room gm *moor mnoomom CSC/SCC - P40
4 Record inmate/patient I ID data.
enyalcian — Pat'detain Resium No.-- tte dornand•
ketee- Tontotoo cluonosts — Won 0 *Our à Friltaitei mospital May 'Oradell
Privition d• te/our S l'nOollei
Ott«
From — Oe
Y-A . 04
L_ Y•A M
I 1 Tomtrrern — Traltenstent
penditure ... 'r,to..acnro den
COOIMenta —ZOLIOrma0.11.•
EIKIlve Feetiltatll
D Non trecti•• Oblisaloire
Monatuto
CND
te-et ea 04
Dental requests must 1 ] be countersigned by
at-tending Physician.
•
•
• PURPOSE:
FORMS INTERRELATED:
COPIES AND DISTRIBUTION:
III(6 ) - 11
ADMINISTRATIVE SUMMARY FORM NO. CSC 377
To provide information to CSC and National Parole
Board authorities on those aspects of an inmate's physical
and mental condition which may effect case management
decisions (e.g. transfer, work load, dissociation). The
information provided is not "Medical Confidential" in
nature.
REFERENCES: Divisional Instructions 700-1-07.1, 700-1-07.2, 700-3-06.1
Policy and Procedures Manual 206, 208
All forms of the Institutional Health Care Record
ORIGINAL - to office or facility requiring information on inmate.
• DUPLICATE - retained on Institutional Health Care Record (Section 6) as record of information forwarded.
TRIPLICATE- for use as needed or discarded.
PROCEDURES: See sample form.
NOTE: Please print or write legibly. Medical terminology should not be used as this summary is intended as a guide for non-medical staff.
Confidential Medical Information: In those instances when an inmate is being transferred, the Institutional Health Care Record cannot follow immediately, and continuity of treatment is a requirement; a case summary should be sent under separate cover marked as follows:
MEDI CAL CONFIDENTIAL TO BE OPENED
BY MEDICAL AND HEALTH CARE
STAFF ONLY
•
CSCrSCG. Nurnercis) de barques oe *années penIcnneles Pe•ierel intormanon Bank Numberls)
P28 Otlefeet tanensenne Abre Des Cannent.
Cam leneerneet en,. I Gaston or cas ICoron
L 040 Sn. nidelne
anale S Nete NOM De Cetera.
Record inmate/patient ID data.
Intenta Sale. N•enera Crat *Menu
F P S Nurn•ro S E D
Ore of brin Date de neuance
APCieseee - Deshrwave
If destination unknown, forward to Classification Officer.
May also include instructions to inmate/patient esco rt s with "ESCORT" in bold print.
ttlE
Car tune, ment D 'en I Mince mena paar•
,Leree.....r.
D à Date
I "
III (6) — 1 2
This form replaces the INTER-INSTITUTIONAL TRANSFER (CSC 59), Fitness Certificate, responses to work boards inquiries, dissociation physical examinations plus other forms which have been institu-tionally developed to transfer health care information to non-medical personnel.
14P Correctionai Service Service correctionnel Canada Canada
MEDICAL AND HEALTH CARE SERVICES
ADMINISTRATIVE SUMMARY
SERVICES MÉDICAUX ET DE SANTÉ
RESUME ADMINISTRATIF
INSTITUTION ETABUSSEMENT
PURPOSE - SUT
Security Mote g multiple lev,) section,/ &poses check M afasroonate blocks)
Frtness ICr - État cie sente pour
D menue 4044444 C. senne mena
D reErre ecgc"...*:.,"`...'",
e- , S.
Nlyeaul,10e SeDunletRemarnue dans le cas 0 un etamissement a multiple myrteao de securge encrier toutes les cases appropneesi
52 53 5. S. 5. Sr Jr-
SUMMAFIY - RESUA1E
hr yout opinion nlhe tomate cnectujiy ana teysen• fil lof normal institukonat aces/aies Inunfer CiSSOCIaiiorn
D'ayeS nous le de tenu est.4 pnyectuernent et mentaxement apte g participer aux actmtes casantes del etaokssernent, a être benstere ou a être puce en isomment ,
.à*. D 'en
NOTE: SOeCthi Soecut care mouvements fo inedicanon connnung Peignent reduced or limited actwites Oenta Status escon instructons NOTA: PrecIser e le oetenu necessge de 501,15 speceux c e51,34.1tre des mechcements un traitement cannnu or,. fettlelen OU Ilhe restriction de Ses dotooles des
barrements oentares OU Si ces cbsoosnions oarticuteres cavent erre ornes lorsotion (escorte
• Dente/ stands - Traitements Centiares necessaires
Enter problems re-quiring immediate or future attention.
May also include in-structions re: medica-tion administration to inmate/patient in tran-sit and/or transfer of medication to receiv-ing HCC.
Aled.caten - Medicarnents
unetabons - Restncbons
OTHE, INFORMATION - AUTRES RENSEIGNEMENTS
APPOINTMENT (An appointreent ha. been eisA. voith) RENDEZ-VOUS (Un renclegnous à étà fixé)
Who Out
Aderess Aorasse
› ,..., p•,..,,......,..., ne.. enne non.
Date ■ • Id 0 .1
Seine.. 01 Amuirent wo.no, Ser.# ...an C4/0 Dec., Sonne du Ovecle mont Cm on agent pennies an nenla Mann
De.
• À ta 0 J
I I Phy.:0114 S nteetwe 14 umuecn Soruo.do Ou mocoon a. feant
0104
il • ta D Only required if under
care of Physician. Adore« - entant
Releasing institutions Health Care Centre.
NOTE: For tunner retagnebon on the rnedca.dentaililItuO ara lirreetiona contact
ROTA: Poix de obus rennes rensmonernenta lei 1«111 de ll Unie gén•roà• el den. Cu neente el Sur ln I elleeten Peetnerellt. veUelle COnntenne eh« •
rllrol'or,. No Pi de r.Na.eri.
CSC SCC 377 On, 3C..
PURPOSE:
REFERENCES:
III(6) - 13
PATIENT AUTHORIZATION TO DISCLOSE CSC FORM NO. 666
PERSONAL HEALTH CARE INFORMATION
To document the authorization by an the inmate/patient of
the release of personal health care information to indica-
ted individual(s) or agencies.
Commissioner's Directive 700-1-07.1
Divisional Instructions 700-1-07.1, 700-1-07.2
Policy and Procedures Manual 108
FORMS All forms of the Health Care Record
INTERRELATED:
COPIES AND One Institutional Health Care Record (Section 6)
DISTRIBUTION:
PROCEDURES: See sample form
NOTE: This form replaces:
Release of Medical, Dental Information, -
MHCS Policy and Procedures Manual, sample form 208-4
Release of Psychiatric Information,
MHCS Policy and Procedures Manual, sample form 208.4
'4
•
PATIENT AUTHORIZATKIN TO SCLOSE CSC PERSONAL HEALTH CARE HIFORMAI1ON
AUTORISATION DU PATIENT RELATIVE À LA otvuLGATIoN PERSONNEL CONTENUS DANS SON DOSSIER DE SANTÉ (SCC)
InMate's name Nam du delenu
tomate s number Numero du detent.
F P S number Numero S E
Record inmate/patient I I.D. data
Persona' iniormation Bank Nurnoerisi Nurrierotsi oe oanoues oe oonnees personnels Date of 'D'Hm
Date de naissance
CSC SCC -
, INSTITUTION 6. , ETABL1SSEMENT r
Healln Care 7-0 sons medicaux
Address of person/ service controlling confidentiality of inmate/pattent§ medical record(s) e.g. institutional HCC, etc.
Addressee - Destinataire
'ro À 1
PersonlAg•ncy - Personne/Organisme Purpose - Motifs
Ill (6) — 1 4
• Cz-xe- • nna Se , y•ct Se,ce canect..1 ,,,e• Caeaca Canaoa
FRONI - DE • I the undersigned authorize the disclosure of personal health care
information contained in my nealth care record tPe ,sonai Information
Bank Numberist to the rolfowing persan or agen
cy for the ourpose indlcated below
Je soussigne autorise la tlieulgeon les rense.g-eme ,••s - •
Que renferme mon dossier ce sanie ■ Nume , 0•5 ae nuna .e • -
nees personnels • a la oe ,.sonn- a, 3 —•
susmenlionne POU' les monts enonces c
Nurse - Nom
Address - Adresse
Notice Io all parties concerned - Avis aux interesses
Health Care Person-nel shall verify in-mate/patient's signature by witness-
.ing or comparing signature with that on form (CSC 4 1 6) MEDICAL HISTORY. In the event the in-mate/patient is deem-ed incompetent, this form may be signed by a legally authorized representative.
CSC medical authorities snall not assume responsibillty for the pro
rection of information disclosed in consequence with the patient s fl
structions Authorized recipients Of suCh information are requested
to treat the information as confidenttal
iris understood Mat this authorization is only valid for the purpose
stated above and for a periocl not to exceed two monthS from the
date of authonzation
PATIENTS AUTHORIZATION - AUTORISATION DU PATIENT
Pabents sionaturx - Sianatuee Ou paiierrr Date
Les autontes meolcates du SCC ne sont pas resPonsacie.
tection des renseignements pe , sonneis cle!uig,es sei: , ire nsn
lions du patient La pe ,sonne ou I organisme du
renseignements es! priee de respecte , leu , ca ,acte ,e cc- .
Il est entendu aue cette autorisation n est ',aride ou a,, ,
nees et DOW une per-iode ne devant pas deDasse . de,- ^10.5
Wimess signature - Signxiu,e oc
CSc eCc • i sa
•
•
0 .1= CI3 0 Z
INC
IV - 1
DIVISION IV COLLECTION OF STATISTICAL DATA
FROM THE INSTITUTIONAL HEALTH CARE RECORDING SYSTEM
This division outlines the methodologies of collecting statistical data from the Institutional Health Care Recording System. The Health Care Recording System refers to the systematic recording and collection of HCC information through the use of a variety of HCC registers and lists.
Note:
At present, 2 statistical data collection forms are in use in CSC insti-tutional Health Care Centres. Copies of these forms and current instructions for their use are duplicated in sub-divisions 4.1 and 4.2.
4.1 Admissions and Discharges Sheet (CSC 484)
The following information was developed as an aid in completing the Admissions and Discharges Sheet (CSC 484).
This A & D sheet is scheduled for revision. A subsequent information package will be forwarded and will replace the one currently in use.
•
•
MO • ••• ••• n
DATE. 19
firomel.t
ttttt I 7•ir pe
SA,n ■ a•
ttttt •1
.....
1+ ADMISSIONS AND DISCHARGES
iM.111 al and 11ealtli Caw vol
MEDICAL CONFIDENTIAL
ADMISSIONS ET SORTIES vol it ■ I•IlIcaux t h•
MEDICAL CONFIDENTIEL
F•deeal Iniormallon
Bank Number 23241
N. de Is band. 1...tale de donnees
CONFINING FACILITY
ETARLISSEMENT D'HOSPIT ALISAT ION
H stun cAnr CEN IRE /REG PSYCH CEN RE
CENTRE DE SOINS DE SANT F./CENTRE REG PSYCH
11 A I •
N
d•
I lllll el, •
Nun.e.o
0.ep. ...... ail
.....
A .....
••• 'Se( 1. IN.,
• • •
•
IV -3
ADMISSIONS AND DISCHARGES SHEET
CSC 484
GENERAL
1. Form CSC 484, Admissions and Discharges Sheet (A&D Sheet), serves as a
permanent record of admissions, discharges and transfers of all hospitalized
offenders and of all deaths occurring in the Health Care Centres, RPCs and
outside hospitals.
2. All health care facilities will maintain Form CSC 484, (A&D Sheet), and
report all in-patients under their care in the following manner:
a. A separate sheet will be maintained for offenders hospitalized in
their own facility as follows:
i. General admissions - Medical and Surgical
ii. Psychiatric admissions
iii. Administrative cases which includes protective custody.
b. In addition, health care facilities shall maintain a separate A&D
sheet for each outside medical facility where offenders from their
population are hospitalized, e.g. patients from Drumheller who are
hospitalized in Drumheller General Hospital, Foothills Hospital,
Calgary General, etc. When the volume of admissions to one or more
outside hospital(s) is small, a single Sheet may be maintained with
an entry referring to the hospital made in the remarks column, e.g.
Drumheller General, Foothills Hospital, etc. opposite each entry.
c. All Admission/Discharge sheets shall be completed in duplicate.
3. When making entries on Form CSC 484, the following instructions shall be
observed:
a. Information should be printed or typewritten and not handwritten.
b. Confining Facilitn The name of the facility confining the patient
shall be entered on the top left hand corner of the page.
c. Health Care Facility/RPC: The name of the reporting institution
shall be entered on the top right hand corner of the page.
•
•
IV - 4
d. Date: Enter the month and year of confinement.
e. Serial Number: On the first day of each month, patients who were
remaining from the previous month(s) shall be listed at the top of
the Admissions and Discharge sfteet for the current month and annota-
ted with the letter "R" in the serial number column. This will de-
note that the patient(s) was/were remaining from the previous month
as indicated in the remarks column marked "Remaining".
Effective the first day of each month, all new admissions will be
assigned with the admission serial number, i.e. 1,2,3,4,5, etc.,
consecutively. This method will simplify the recording of statis-
tics on the three types of admissions in table 3a, 3b, 3c (Bed Care)
of the CSC 30 Health Care Centre Activities Report.
f. Inmate Number: Enter the applicable inmate number for each admis-
sion.
g. Name and Initials: Enter name and initials as applicable to the
offender being admitted.
h. Diagnosis: The column for diagnosis is divided into (2) two sub
columns marked "Diagnosis on Admissions" and "Diagnosis on
Discharge".
i. Diagnosis on Admission
Write in the provisional or first diagnosis when the offender
has been admitted.
ii. Diagnosis on Discharge
Write in the final diagnosis when - the patient has been dis-
charged. If there is no change in the diagnosis since admis-
sion, write in the word "same".
NOTE: These diagnoses are used for hospital morbidity coding and sta-
tistical purposes at NHQ.
i. Date
i. Date of Admission
The date of admission shall be recorded for all patients admit-
ted. i.e. 83.01.15.
ii. Date of Discharge
The date of termination of in-patient treatment will be record-
ed, i.e. 83.01.18.
•
•
•
IV - 5
• j. Days
i. Hospital Days
Enter the total volume of in-patient care expressed in
"Patient-Days" (Hospital Days) during the month. Refer to the
following Chart A.
ii. Discharge Days
Enter the accumulated patient days since the admission of the
offender who was discharged from or who died during the month
while in the Health Care Centres, RPCs or outside hospitals.
The count of total days stay or discharge days (from date of
admission) is required for the calculation of average length of
stay of hospital discharge cases. The day of admission is to
be counted, but not the day of discharge.
k. Remarks Column: Enter any significant remarks referring to the
case, also if hospitalized in outside hospital(s), the name of the
hospital is to be entered, transfer to or from civilian hospitals or
other institution or remaining at end of the month, etc.
PROCEDURES AT END OF CALENDAR MONTH
4. New sheets of the form CSC 484 shall be started for each calendar month.
On the first day of each month, the pages of the form CSC 484 for the previous
month shall be closed off by annotating all cases in Health Care Centres, RPCs
or outside hospitals as "Remaining" in the reffiarks column. Details on
patients remaining in the Health Care Centres, RPCs or outside hospitals from
the previous month shall be carried forward to the current month using the
letter " R " in the column marked "Serial Number".
5. Duplicate page(s) of the form CSC 484 from the previous month shall be
removed and forwarded to NHQ (Ottawa) attached to the Health Care Centre Acti-
vities Report (CSC 30) by the 15th day of each month.
6. The original copies of the A&D sheets ar.Q to be retained and stored by
the HCC and RPC for use as a permanent record Of the inmates hospitalization.
•
IV - 6
7. Once the form(s) have been completed they shall be treated as "Medical
Confidentialn. Mailing instructions for confidential material will apply when
forwarding to DGMS, NHQ.
8. Admission and Discharge sheets for NHQ are to be forwarded to the follow-
ing address:
The Correctional Service of Canada
National Headquarters
Medical and Health Care Services
340 Laurier Ave. West
Ottawa, Ontario KlA 0P9
Attention: Health Care Information Analyst
CHART TO ILLUSTRATE THE COUNT OF HOSPITAL DAYS DURING THE MOMTH
CHART A
PREVIOUS MONTH NEXT MD P (JULY) REPORTING MONTH (AUGUST) SEPT
26 27 28 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 ADM DIS
A E ----- 1-1 ADM DIS
8
io
] .
ADM DIS
C
E: 31 ii ADM DIS
D 8 1 _ ADM DIS . ,
E 15 li
ADM DIS
F 15 J
ADM
G 5 -1
TOTAL HOSPITAL DAYS ADM DIS . 84 DAYS
H *HOSPITAL DAYS (PATIENT-DAYS) DURING 711E MONTH REPORTED
This is the total volume of inpatient care, expressed in patient -days of the hos- pital during the month. This count Is used in a great variety of calculations to express hospital activities and costs on a per diem basis.
•
•
1 0
31
08
15
15
5
•
•
IV - 7
CHART A (CON I T)
HOSPITAL DAYS
Patient A No days counted, because no service was provided during the reporting month Admission on the 26th July, discharged on the 30th July
8 Count only the days for the reporting month (10 days), exclude day of discharge Admission on the 29th July, discharged on the llth August
C Count only the days for reporting month (31 days) as patient days occurred during the reporting month Admission on the 20th July, discharged on the 4th of September
Count all days of care, (08 days plus 15 plus 15) because all were provided during the reporting month, excluding days of discharge D - Admission on the 2nd of August, discharged
on the 10th of August E - Admission on the 7th of August, discharged
the 22nd of August F - Admission on the 9th of August, discharged
on the 24th of August
G Count days from admission including last day of month (total 5 days) becuse these days were provided during the reporting month Admission on the 27th of August, discharged on the 20 September
H DO NOT COUNT ANY DAYS, because no service was provided during the reporting month. Admission on the 2nd of September, discharged on the 4th September
TOTAL HOSPITAL DAYS 84
NOTE: Previous Month = July Reporting Month = August Next Month = September
D E F
REVISED 1983-05-05
HEALTH CARE CENTRE ACTIVITIES REPORT
RAPPORT D'ACTIVITÉS DU CENTRE DE SANTE
Leper. on•'0••••••111.0 ,
• 8 .'• • '5•••".••• 23241 ; te neerfi, •.' te neerfi,
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CE•5vol. II 5Ar4TE
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I 1E ..or•-• no no, u•• •-oen•, <
2 ROUTINE PHYSICAL EXAMINATIONS - EXAMENS MEDICAUX COURANTS
; ke
3 BED CARE - INFIRMERIE
In•e..1 0
Eao ono.. °moos I lAuteot
F000rgon,esourts.0 0 Oso4r
,goncos ae ••ee ■ > c I
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Otnet•CSC Geneta. •.sroo.a1••5
Sons Aot,es.SCC Genet.
SO••••• pene•iy• OSV, el••Mvel
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I i I ; 1. 1 1 4 SPECIALISTS VISITS - VISITES A DES SPECIALISTES
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7 RADIOGRAPHY PROCEDURES - RADIOGRAPHIES
osta o•• a. SC.: cpc • .1 s••••• r •
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9 IMMUNIZATION - IMMUNISATION
e. :•••••••• so
Goo-o••••ove V•t• c. e0•S• ,, t
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A
IV - 8
4.2 Health Care Centre Activities Report (CSC 30)
The following guide was developed as an aid in completing the Health Care .
Centre Activities Report.
This form is scheduled for revision. A subsequent guide will be forward-
ed and will replace the one currently in use.
NOTE O. not type in NOTE Fie nu OKtvio•OroPO. , !Gate
ekteded areas dens no eepaees ombrés ! Yee Mon••• cone, Moos
I II I 1 GENERAL CLINIC - CONSULTATIONS GENERALES
Div
O..
DE%0MOWFME, , 0E S ..5 4 _ACE,
O•oe• no. qa t L...1•es "OG
:Ft •1
eec oct..ra• -
••••DoC DE - E , A5t. SSEMEN.
5 THERAPEUTIC PROCEDURES - THERAPIES 6. LABORATORY PROCEDURES - EXAMEN DE LABORATOIRE
A
I-
; B
8 SUFIGICAL OPERATIONS INTERVENTIONS CHIRURGICALES
F../7•.; •a. •. ', etc • ■• ^C. at a" i0••• ■••• CSC. •oe R .O..•••• o• SCC -• C5C
A i S
! I !
10 INFECTIOUS DISEASES 1/3r00m/tin. - MALADIES INFECTIEUSES IDerent Nor. Fob'« don repo-on/
s
D
1 1 1 1 Sognattoe o• assotaoo .•■■ •or- nraon
• Sognoture• Ou Do•ro:••••• ■ ••br.rot,sn•ns or son,
DISTRIBUTION Whote DOMS 1CSC NHOI Cane., HCC 1Mo/flout officer. Ifirer RUM 6 HCS DIFFUSION Blanc ()GSM ISCC A C CSS lAtr rentoectnt Rote AR SMS
Oat.
• II
IV -9
GUIDE FOR USE OF
HEALTH CARE CENTRE ACTIVITIES REPORT
This report records statistics on designated types of health care servi-
ces performed at or provided through institutions with health care centres.
Separate reports for Farm Annexes or other minimum security institutions serv-
ed by Health Care Centres in other institutions are not required.
A copy of the form is included. It consists of ten separate sections on
types of health care services provided. The number of inmates treated or pro-
cedures done shall be printed or typed in the blocks provided. Instructions
on how to complete all parts of the form are provided in this guide.
Health Care Centres shall complete a report for each month of the year.
The report is to be distributed as indicated on the bottom of the form, with
the original or duplicate copies reaching their destinations no later than the
• 15th day of the following month.
Distribution: Original: Director General
Medical and Health Care Services
The Correctional Service of Canada
340 Laurier Ave. West
Ottawa, Ontario
KlA OP9
Duplicate: Retained by the reporting Health Care Facil-
ity, with a copy to be given to the institu-
tional physician.
Triplicate: To be sent to the Regional Manager, Medical
and Health Care Services
IDENTIFICATION
The name of the institution shall be put in the block 'Health Care
Facility" at the top of the form. The month and year for which the report has
been prepared shall be entered on the next block on the same line. It is not
necessary to put down the day or days on which the report was prepared. •
IV - 10
SECTION 1 - GENERAL CLINIC
A. Visits By Inmates: The total number of visits by all inmates to the
Health Care Centre General Clinic (excluding the medication parade) for
the month shall be recorded in this block. For example, if Inmate X
appears six times during a month, this is counted as six visits.
A visit is defined as:
an appearance by an inmate at a scheduled clinic or at any other -
time (for example, in an emergency), OR
a visit by a Health Care Officer to an inmate in an area outside the
Health Care Centre, OR an appearance by an inmate when sick parade is held in an area out-
side the Health Care Centre.
Appearances by staff at the Health Care Centre are not to be recorded.
B. Seen by Medical Officer: The total number of visits by all inmates to
the Medical Officer (Physician) shall be recorded in this block. Th is
number includes inmates who have been referred by Health Care Centre
Staff from the General Clinic or by other means.
C. Emergencies - Outside Hospitals: The number of incidents where inmates
are removed from the institution and are treated at an outside hospital,
on an emergency basis, shall be recorded in this block. Visits by staff
to outside hospitals for these reasons are not to be recorded.
SECTION 2 - ROUTINE PHYSICAL EXAMINATIONS
A. Reception: The total number of complete physical examinations during the
month that have been done on inmates on initial reception shall be recor-
ded in this block. Reception is defined as entry into the system at a
Regional Reception Centre or as direct entry at a receiving institution,
which includes inmates transfered from provincial institutions.
•
•
B. Transfer: The total number of physical examinations conducted on inmates
on transfers within CSC shall be recorded in this block. A transfer
occurs when an inmates moves from an institution in one security level to
an institution in another security level or to some type of supervised
IV - 11
environment in the community. For example:
from a medium security institution to a camp
from a maximum security institution to a medium security insti-
tution
from a medium security institution to a maximum security insti-
tution
C. Release: The total number of physical examinations on inmates to be
released from penitentiary shall be recorded in this block. Release is
defined as some form of long-term release into the community, such as
full parole or mandatory supervision.
D. Annual: The total number of annual physical examinations conducted on
inmates during the month shall be recorded in this block. Annual physi-
cal examinations done on staff shall not be recorded.
E. Other: The total number of other types of physical examinations done on
inmates during the month shall be recorded in this block. Examples are
examinations done before short-term release, like temporary absence or
limited day parole.
SECTION 3 - BED CARE
This section of the form shall be filled out by all facilities where hos-
pitalization is provided within the institution. Data should represent
events that take place from one minute after midnight on the morning of the
first day of the month to midnight of the last day of the . month.
Health Care Centres with bed-care facilities will report all admissions,
even if an inmate has been sent from another institution for treatment. In
addition, all inmates sent to other CSC facilities or to a hospital outside
CSC shall be reported as such.
Two types of data must be reported - admissions and hospital days. Each
is divided into two categories - general medical care; which includes all
types of non-psychiatric care and treatment; and psychiatric care. (3.C. -
3.1). Inmates who are admitted to a facility for protective custody or for •
IV - 12
other administrative reasons in an emergency are counted under the heading
"Administration".
Definitions:
Admission: an instance where an inmate has entered a bed-care facility
for the purpose of receiving medical and hospital services, who has been
assigned a hospital bed and who will have a record of this hospital
treatment created or maintained.
Hospital Day: a unit of measure of bed-space provided during an
inmate's stay at a hospital facility. The day of admisson is always
counted as one hospital day but the day of discharge is never counted.
For example, when an inmate is admitted one day and discharged on the
next day, only one hospital day shall be counted. Also, when an inmate
is admitted and discharged on the same day, only one hospital day shall
be counted. For example on how to count hospital days over an entire
month of more, see Chart A (Attached to this guide).
NOTE: "Section 3 - Bed Care" may be omitted if Admission and Discharge
Sheets are kept for all inmates hospitalized in the Health Care Centre,
at other CSC facilities and at hospitals outside CSC, and are sent to
Regional and National Headquarters along with the"Health Care Centre
Activities Report at the regular time every inonth. A standard CSC form
is available from the CSC Supply System for this purpose.
The blocks in the third section are to be filled out in the following
manner:
A. Own Facility - General - Admissions
G. Own Facility - General - Hospital Days: The number of admissions
and the number of hospital days during the month for inmates hospi-
talized for any non-psychiatric type of medical treatment at the
institution's health care centre shall be noted in this block.
•
B. Own Facility - Psychiatric - Admissions
H. Own Facility - Psychiatric - Hospital Days: The number of admis-
sions and the number of hospital days during the month for inmates •
•
IV -13
hospitalized for psychiatric types of care at the Health Care Centre
shall be recorded in this block. For example, some inmates receive
psychiatric care in the institutional health care centres, particu-
larly in the Atlantic Region.
C. Own Facility. - Administration - Admission
I. Own Facility - Administration - Hospital Days: The number of
inmates who are admitted (including hospital days) to a facility for
protective custody or for other administrative reasons in an emer-
gency shall be recorded in this block.
D. Other CSC Facilities - General - Admission
J. Other CSC Facilities - General - Hospital Days: The number of
admissions and the number of hospital days during the month for
inmates who have been hospitalized for general medical care at other
CSC facilities shall be recorded in this block. For Example, an
inmate may be sent for a surgical operation to Kingston Pen from
Millhaven, stay for three days and then return to Millhaven after
the treatment had been completed. If an inmate is sent to another
CSC facility for long-term psychiatric care, he/she.will be perman-
ently transferred to that facility. Therefore, the admission of an
inmate to a Regional Psychiatric Centre, for example, shall not be
recorded on this form.
E. Facilities Outside CSC - General - Admissions
K. Facilities Outside CSC - General - Hospital Days: The number of
admissions and the number of hospital days during the month for
inmates who have been hospitalized for general medical treatment at
hospitals outside CSC shall be recorded in this block.
F. Facilities Outside CSC - Psychiatric - Admissions
L. Facilities Outside CSC - Psychiatric - Hospital Days: The number of
admissions and the number of hospital days during the month for
inmates who have been hospitalized for psychiatric care at facili-
ties outside CSC (such as provincial or private hospitals) shall be
recorded in this block. For example, in the Quebec Region, an
inmate may be sent for psychiatric treatment to the Philippe Pinel
Institute in Montreal and stay for a significant length of time.
IV - 14
M. Bed Occupancy - Daily Average: This block will show the extent to
which hospital facilities in the Health Care Centre are being util-
ized. The number (calculated to the first decimal place - e.g.,
10.7) is computed by dividing the total number of hospital days
(general care, psychiatric care and administration) at the Health
Care Centre for the month by the number of days in the month:
84 hospital days = 2.7 beds occupied (on average) per day
31 days in month
SECTION 4 - SPECIALISTS' VISITS
The total number of times inmates see a consulting physician or special- .
ist in a particular medical discipline inside or outside the institution dur-
ing the month shall be recorded in the appropriate blocks in this section.
The form has separate blocks for several types of specialization; if a partic-
ular type is not shown by name, the number should be shown in the total number
under the general heading "Others".
Specialists may see inmates in facilities provided at the Health Care
Centre. Such visits should be recorded in blocks in the form labelled "Inside
Institution". When inmates are seen by specialists at outside clinics or as
part of treatment at other facilities (inside or outside CSC), visits should
be recorded as part of the total in blocks on the form labelled "Outside
Institution".
Following is a list of the individual blocks included in this section:
A. Ophthalmology & Optometry - Inside Institution H. Ophthalmology & Optometry - Outside Institution B. Orthopaedics - Inside Institution I. Orthopaedics - Outside Institution C. Dermatology - Inside Institution
J. Dermatology - Outside Institution D. Ear, Nose and Throat CENT) - Inside Institution K. Ear, Nose and Throat (ENT) - Outside Institution E. General Surgery - Inside Institution
L. General Surgery - Outside Institution
IV - 15
F. Psychiatry - Inside Institution
M. Psychiatry - Outside Institution 11, G. Others - Inside Institution
N. Others - Outside Institution
SECTION 5 - THERAPEUTIC PROCEDURES
A. Physiotherapy - Number of Inmates: The number of inmates provided with
physiotherapy services by a qualified physiotherapist will be reported in
this block. All inmates receiving such treatment, regardless of whether
it is available inside the institution or only in outside facilities,
shall be reported in this block.
B. Other Therapy - Number of Inmates: The number of inmates provided with
other types of therapy (such as speech therapy, occupational therapy or
cobalt therapy) will be reported in this block. In the same way as the
previous block, inmates receiving treatment inside or outside the insti-
tution shall be reported in the same total number.
SECTION 6 - LABORATORY PROCEDURES
A. The total number of laboratory procedures done during the month shall be
recorded in this block. A laboratory procedure is defined as a labora-
tory test carried out on specialized equipment, usually by a qualified
laboratory technologist. Quick-indicator tests (such as dip-stix for
urinalysis) or procedures which only obtain samples and do not test them
are not to be counted as laboratory procedures. Since it is likely that
a very large proportion of the tests will be carried out in facilities
outside the institution, only one block to record the total number of
tests during the month is required.
SECTION 7 - RADIOGRAPHY PROCEDURES
A. Number of Inmates: The total number of inmates X-rayed • at the institu-
tion, at another CSC facility and at facilities outside CSC shall be
recorded in this block.
•
•
IV - 16
B. Examinations - Own Facility
C. Examinations - Other CSC Facilities
D. Examinations - Facilities Outside CSC: The total number of examinations
done in each of three categories (own facility, other CSC facilities,
facilities outside CSC) during the month shall be recorded in the appro-
priate blocks. An examination is defined as one or more X-ray films
taken at the same visit for the diagnosis of a particular problem. For
example, an inmate who has X-rays taken of his ankle and his shoulder has
had two examinations done at the same visit.
SECTION 8 - SURGICAL OPERATIONS
A. Surgical Operations - Own Facility
B. Surgical Operations - Other CSC Facilities
C. Surgical Operations - Facilities Outside CSC: The total number of surgi-
cal operations carried out inside and outside the institution during the
month shall be recorded in the appropriate blocks in this section. The
location where the surgical procedure was done (that is, while hospital-
ized in the Health Care Centre or in a visit to the - General Clinic) or
the type of surgery performed (level 1, 2 or 3) should not be recorded.
SECTION 9 - IMMUNIZATION
•
•
A. Number of Inmates
B. Number of Inmates
- Tetanus
- Influenza
C. Number of Inmates - Allergy
D. Number of Inmates - Others (Specify): The total number of immunization
and innoculations performed during the month shall be recorded in the
appropriate blocks in this section. If a procedure does not fit in a
specific block, record it under the heading "Others" and specify the num-
ber and type of immunization performed. •
IV - 17
SECTION 10 - INFECTION DISEASE (REPORTABLE)
A. Number of Cases - Tuberculosis
B. Number of Cases - Syphilis
C. Number of Cases - Gonorrhoea
D. Number of Cases - Viral Hepatitis
E. Number of Cases - Others (Specify): The number of cases of infectious
diseases that are diagnosed during the month shall be recorded in this
section of the form. Record the number of cases of each type in the
appropriate block. If a case does not come under a specific heading,
record it under the heading "Others" and specify the number of cases and
specify the type of disease. Infectious diseases that are reportable by
law to provincial authorities are to be recorded in this section. They
must be recorded regardless of whether the diagnosis is made upon recep-
tion or after the inmate has been in the institution for some time. If
there is a positive test result but in the interim the inmate has been
transferred to another institution, the receiving institution will report
the incidence of the disease.
Section 11 - Enter dental services.
Section 12 - This block will be used for future reporting of a statisti-
cal nature only when requested by this office.
SIGN OFF
The Assistant Warden, Health Care Services (or delegate) shall sign the
Health Care Centre Activities Report to verify its accuracy and completeness.
The signature shall be written in the space provided, and the date shall be
indicated. A copy of the completed form shall be supplied to the Institution •.e.
Medical Officer.
•
8
15
15
PATIENT PREVIOUS MONTH * REPORTING MONTH NEXT MONTH
adm disch
- - -1
adm . . . disch
[I 10]
D
G
H
adm
TOTAL HOSPITAL DAYS = 84 DAYS
31
adm..1. . . disch
5
A
E:
adm disch
adm . . . disch
adm . . disch
adm disch
Ei •.7 ■■•
disch
IV -18
CHART A
CHART TO ILLUSTRATE THE COUNT OF HOSPITAL DAYS DURING THE MONTH
* HOSPITAL DAYS (PATIENT-DAYS) DURING THE REPORTING MONTH
This is the total volume of inpatient care, expressed in patient-days of the hospital during the month. This count is used in a great variety of calculations to express hospital activities and costs on a per diem basis.
•
•
•
•
IV -19
CHART A (CONT'D)
PATIENT A - No days counted, because no service was provided during the
reporting month.
B - Count only the days for the reporting month (10 days), exclude
day of discharge.
C - Count only the days for reporting month (31 days) as patient
days occurred during the reporting month.
D, E, F - Count all days of care, (8 days plus 15 plus 15).
- Because all were provided during the reporting month.
Excluding days of discharge.
G - Count days from admission including last day of month (total 5
days) because these days were provided during the reporting
month.
H - DO NOT COUNT ANY DAYS, because no service Was provided during
the reporting month.
•
•
>c rn
ANNEX A
•
•
HEALTH CARE RECORDS MANAGEMENT CHECKLIST
This Annex presents the Health Records Management Audit Checklist, which describes all the necessary forms and procedures that must be found in an effective HCC. The checklist may be used for:
1. MEDICAL AND HEALTH CARE SERVICES FUNCTIONAL STAFF REVIEWS
2. INSPECTOR GENERAL MANAGEMENT REVIEW
WHO CAN USE
The following questions are designed to examine central policies and issues within health care records management. They do not require the auditor to examine in detail the individual health care record.
As such, the checklist can be used by CSC generalists as well as medical branch program staff. In the former case, the confidentiality of information is not a problem.
1. USE OF STANDARD FORMS
1.1 Standard Forms
(pertains only to those medical/confidential forms filed in the Institutional Health Care Record Jacket(CSC 403)).
Does the health care centre have a stock of the following forms:
SERIAL TITLE YES NO
CSC 49 Laboratory Report Record
CSC 51 Radiography Requisition and Report
CSC 55 Patient Medication Record
CSC 56 Consultation Report
•
SERIAL TITLE YES NO
CSC 57 Major Problem List
CSC 61 General Physical Examination
CSC 133 Dental Record
CSC 377 Administrative Summary
CSC 378 Record of Immunization
CSC 403 Health Care Record Jacket
CSC 416 Medical History
CSC 418 Admission/Reception Medical Procedures
CSC 469 Treatment Record
CSC 471 Doctor's Orders and Progress Notes
CSC 552 Request for Medical Services
CSC 571 Inpatient Case History
CSC 666 Patient Authorization to Disclose CSC Personal Health Care Information
1.2 Forms Procurement
Procurement of standard forms is a perennial problem for many HCCs. An adequate and timely supply of forms is one . means of ensuring maintenance of standard record systems.
Q. Are there any outstanding orders for forms? If yes, please list the outstanding form(s) and the date ordered.
1.3 Local Forms
Please ensure that any forms used in the HCC which do not bear a CSC number are photocopies and their use stated. Photocopies to be sent to NHQ.
Attention: Medical Services Branch Office Manager
•
2. CONTROL OF ACCESS
2.1 Do the health care staff control physical access to the current * (active and inactive) Institutional Health Care Record.
* Health Care Records of ininates currently serving a sentence at a facility served by a particular Health Care Centre.
2.2 Are current (active and inactive) volumes of Institutional Health Care Records stored within the physical confines of the Health Care Centre? If no: does their location jeopardize health care staff access to the records; are they accessible only to health care staff.
2.3 Are active and inactive records accessible by health care staff on a 24 hour basis?
2.4 Are dormant records held at the institution accessible during the working day?
3. STORAGE
3.1 Active/Inactive
gl, Are the active and inactive records stored in sequential or alphabetic order to ensure rapid access?
3.2 Current Record Register -
Does the health care centre maintain a currènt register of active and inactive Health Care Records?
3.3 Dormant-Institution
Are dormant Institutional Health Care Records properly sealed and annotated with:
MEDICAL CONFIDENTIAL TO BE OPENED
BY MEDICAL AND HEALTH CARE
STAFF ONLY
plus the inmate's name, FPS and Warrant Expiry date (WED)?
•
•
4. RECORD RECALL
4.1 Backlog of Recalled Records
Does the Health Care Centre maintain a register of outstanding records. If yes, is there a backlog of records on request? How many? How long?
4.2 Temporary Records
Please verify that a temporary record has been created for each record on the recall list.
5. ORIENTATION OF STAFF
5.1 Orientation Training
Does orientation training for new health care personnel include a review of DI 700-1-07.1: Management of Health Care Records and DI 700-1-07.2:- Confidentiality and Use of Health Care Information.
•
Saskatchewan Pen Saskatchewan Farm Annex RPC (Prairies) Edmonton Stony Mountain Rockwood Bowden Drumheller Drumheller Annex
PRAIRIES: RHQ
B - 1
ANNEX B
INSTITUTIONS ELIGIBLE TO RECEIVE AND STORE HEALTH CARE RECORDS
ELIGIBLE INSTITUTIONS ELIGIBLE INSTITUTION HOLDS RECORDS OF:
ATLANTIC: RHQ Dorchester Westmorl and Springhill
QUEBEC: RHQ RRC CDC Archambault Ste-Anne des Plaines Laval Montée St-François Cowansville FTC Leclerc La Macaza Drummond 1
ONTARIO: RHQ RTC (Ontario) Prison for Women Kingston Pen Millhaven Bath Joyceville Pittsburg Warkworth Collins Bay Beaver Creek Frontenac
PACIFIC: RHQ Kent Elbow Lake RPC (Pacific) Mountain Willjam Head Mission Ferndale Matsqui
C - 1
ANNEX C
11, PROCUREMENT OF FORMS AND OTHER SUPPLIES
1. Procurement of Forms
(Information forthcoming based on impending CD's and DI's from Forms
Management and Technical Services)
2. Procurement of TAB Compucolor Numeric Labels for Institutional Health
Care Record File Jackets
The Institutional Health Care Record File Jackets are designed to
indicate the inmate's FPS number, through the use of individually-coloured
stickers (one colour for each number 0 to 9) on the outer right tab of each
file, starting from the top square and working towàrds the bottom of the file.
The filing system in each HCC was implemented using the TAB Compucolor
Labels. It is very important to the efficiency of this system that when reor-
dering labels they be strictly equivalent. This applies to colour, size and
design. Labels which are not the correct colour or shape, will defeat the
purpose of the system as the colour bars will not properly match.
TAB labels are printed on vinyl and have a mat finish. The colour bar is
solid with a black outline. The actual digits are reverse-printed in the same
colour outside the bar on a white background.
•
Shown on the next page are sampie labels and numbers with the correspond-
ing colours. •
• 0 DARK GREEN P INK
LIGHT BLUE RED 6
• 7 2 PURPLE L IGHT ORANGE
DARK ORANGE LAVANDER 3 8
L I GHT GREEN 4 BROWN
•
• MONTREAL
2373 46th Avenue
Lachine, Quebec
H8T 3C9
1-(514) 636-0960
VANCOUVER
104, 1675 West 8th Avenue
Vancouver, B.C.
V6J 1V2
1-(604) 736-3431
• Method of Ordering: For expansion purposes, self-adhesive labels are
available in dispenser boxes of 500 labels each. These products are available
through any of TAB's branches across Canada. Installations situated outside of
these cities should contact the nearest TAB office, who will refer them to the
agent handling that area as noted below. Health Care Centers should advise
their supply office of these instructions to maintain uniformity in the sys-
tem.
TAB PRODUCTS OF CANADA LTD.
OTTAWA
1898 Courtwood Crescent
Ottawa, Ontario
K2C 2B5
1-(613) 226-3660
•
• 1-(403) 244-3328 CALGARY
7-1044A 17th Avenue S.W.
Calgary, Alberta
T2T 008
TORONTO
550 McNicoll Avenue
Willowdale (Toronto) Ontario
M2H 008
1-(416) 494-0077
If further information is required, please contact
NHQ (Medical Services 993-5073).
3. Procurement of Avery Stickers
(Information forthcoming based on impending CD's and DI's from Forms
Management and Technical Services)
•
• 4. Procurement of Inmate Number Labels and Offender Data Labels
(Information forthcoming based on impending CD's and DI's from Forms
Management and Technical Services)
Note: Effective June, 1984 - Inmate Number Label obsolete.
•
•
• D - 1 • ANFEXD
ROUTINE MEDICAL AMI HEALTH CARE INFORMATION REQUIRED FOR ADMINISTRATION PURPOSES (A REFERENCE CHART)
ACTIVITY/ INFORMATION MEDICAL FORMS ADMIN.FORM UTILIZED FOR PURPOSE OF ADMIN. FORM/
UNIT EVENT REQUIRED BY REFERENCES PROVIDING INFORMATION TRANSFER OF INFORMATION INFORMATION REQUIRED
1. RECEPTION
PROCESS
a. Free from Case Management Team MHCS Policy and Medical History (CSC 416) Administrative Summary Detection and prevention
Infection Procedures Manual, (CSC 377) of communicable diseases
Inspection Section 200 or infestation.
b. General Case Management Team MHCS Policy and General Physical Examina- Administrative Summary Assessment of physical and
Physical Procedures Manual, tion (CSC 61) (CSC 377) mental status of inmate.
Examination Section 202 Identification of factors
Medical History (CSC 416) which could or should
limit program involvement
or terms of incarceration.
2. TRANSFER
a. To a minimum Case Management Team MHCS Policy and All forms of the Institu- Administrative Summary Assessment of physical and
security Procedures Manual, tional Health Care Record (CSC 377) mental status; possible
facility Section 208 limitations.
b. To another Security escort MHCS.Policy and All forms of the Institu- Administrative Summary Continuity of treatment
facility during transfer. Procedures Manual, • tional Health Care Record (CSC 377) during and post-transfer.
with a HCC Health care staff on Section 208 Indicates limitations due
duty to medical condition(s).
D - 2
ANNEX D
ROUTINE MEDICAL AND NEALT4 CARE INFORMTION REQUIRED 0-.R ADMINIsTRATiom PURPOSES (A REFERENCE CHART)
ACTIVITY/ INFORMATION MEDICAL FORMS ADMIN.FORM UTILIZED FOR PURPOSE OF ADMIN. FORM/
UNIT EVENT REQUIRED BY REFERENCES PROVIDING INFORMATION TRANSFER OF INFORMATION INFORMATION REQUIRED
c. To a parole Parole, CCC or CRC MHCS Policy and All forms of the Institu- Administrative Summary Continuity of treatment
office, CCC staff Procedures Manual, tional Health Care Record (CSC 377) during and post-transfer.
or CRC. Section 208 Indicates limitations due to medical condition(s).
3. GENERAL CLINIC
a. HCC out- Living Unit Officer All forms of the Institu- Administrative Summary Indicates limitations due
patient tional Health Care Record (CSC 377) to medical condition and
visit treatment.
b. HCC Hospi- Living Unit Officer All forms of the lnstitu- Administrative Summary Administrative arrange- talization tional Health Care Record (CSC 377) ments.
4. PROGRESS Case Management Team Case Management All forms of the Institu- Case Management form: Need for medical or
SUMMARY Manual, Chapter 19 tional Health Care Record Progress Summary psychiatric clearance. (CSC 430)
5. DISCHARGE Case Management Team MHCS Policy and All forms of the lnstitu- Administrative Summary Documentation of physical PHYSICAL Procedures Manual, tional Health Care Record (CSC 377) and mental status.
Section 208 Assessment of need for
further treatment. Prog- nosis concerning tempor- ary or permanent disabil- ities.
• •
• D - 3 • • ANLE X D
ROUTINE MEDICAL AND HEALTH CARE INFORMATION REQUIRED FOR ADMINISTRATION PURPOSES (A REFERENCE CHART)
ACTIVITY/ INFORMATION MEDICAL FORMS ADMIN.FORM UTILIZED FOR PURPOSE OF ADMIN. FORM/ UNIT EVENT REQUIRED BY REFERENCES PROVIDING INFORMATION TRANSFER OF INFORMATION INFORMATION REQUIRED
6. POST RELEASE General data on MHCS Policy and All forms of the Institu- Administrative Summary Continuity of treatment
TREATMENT requirements to Procedures Manual, tional Health Care Record (CSC 377) during and post-release.
parole offices, CCC Section 208.4 Indicates limitations due
or CRC staff. Patient Authorization to to medical condition.
Detailed summary to Disclose Information
community medical (CSC 666)
staff with patient
consent.
7. ACCIDENT AND Institutional MHCS POlicy and Doctor's Orders and Progress (Form currently under Documentation of cause,
INJURY Administration Procedures Manual, Notes (CSC 471) development) time and extent of acci-
RECORDING Section 304.2 dent or injury; including
action taken and when.
8. MEDICAL Case Management Team Case Management All forms of the Institu- Transfer to an Acute Documentation of reason,
TEMPORARY Living Unit Officer Manual, Chapter 19 tional Health Care Record Care Facility (CSC 50) destination, means of
ABSENCE FOR transport, escort needs,
HOSPITAL OR Admin. Summary (CSC 377) etc.
REFERRALS '
9. DISSOCIATION Case Management Team MHCS Policy and ' All forms of the Institu- Administrative Summary Fitness assessment of
Procedures Manual, tional Health Care Record (CSC 377) inmate for dissociation.
Section 206
= =I m ›‹
•
INDEX - 1
SUBJECT PAGE
A ACCIDENT (See also INJURY)
ACTIVE FOLDER
Organization
ADMINISTRATIVE SUMMARY (CSC 377)
II-1, D-3
iv, II-1, I1-2, A-3 III-1, 111-4
I1-2, III(6)-11, A-2, D-1, D-2, D-3
ADMISSION/RECEPTION MEDICAL PROCEDURES (CSC 418) .. 111(6)-2, A-2
ASSISTANT WARDENS HEALTH CARE SERVICES
AVERY STICKERS
CONFIDENTIAL
CONSULTATION REPORT (CSC 56)
1-4, IV-17
111-2, C-4
II-3, 111-2, 111(4)-2, 111(5)-2 111(5)-4,111(6)-11 IV-6, A-1, A-3, A-4
111(4)-2, 111(6)-3 A-1,
CSC FORMS (CONDENSED COPIES) (See also individual forms listed by name)
(CSC 49) Laboratory Report Record 111(5)-3 (CSC 51) Radiography Requisition and Report 111(5)-5 (CSC 55) Patient Medication Record 111(3)-4 (CSC 56) Consultation Report 111(4)-3 (CSC 57) Major Problem List III(1)-3 (CSC 61) General Physical Examination III(1)-8 (CSC 133) Dental Record III(1)-13 (CSC 377) Administrative Summary 111(6)-12 (CSC 378) Record of Immunization III(1)-11 (CSC 403) Health Care Record Jacket 111-2 (CSC 416) Medical History III(1)-5 (CSC 418) Admission/Reception Medical Procedures 111(6)-3 (CSC 469) Treatment Record 111(2)-5 (CSC 471) Doctor's Orders and Progress Notes 111(2)-3 (CSC 552) Request for Medical Services III(6)-10 (CSC 571) Inpatient Case History 111(6)-5 (CSC 666) Patient Authorization to Disclose
Personal Health Care Information 111(6)-14
•
•
•
SUBJECT PAGE
CURRENT HEALTH CARE RECORD
Organization
CURRENT REGISTER
DEATH
DENTAL
DENTAL RECORD (CSC 133)
DENTURES
DIRECTOR GENERAL, MEDICAL SERVICES
DIRECTOR, INFORMATION ACCESS AND RECORDS MANAGEMENT - NHQ
DIRECTOR, PREVENTIVE SECURITY - NHQ
DISCHARGE (See also RELEASE)
DISSOCIATION
DOCTOR'S ORDERS AND PROGRESS NOTES (SCS 471)
DORMANT HEALTH CARE RECORD recall storage
DRUG (See also MEDICATION)
ELECTIVE
FINAL NOTE (Pen 1115)
iv, II-1, II-2, A-4 III-1
II-2,A-3
1V-3
111(6)-3,111(6)-10 111(6)-12
III(1)-12, A-2
III(1)-6
I-3, 111(6)-9, IV-6, IV-9
I-3
I-3
II-3,111(6)-5
iv, III(6)-11, 111(6)-12, IV-3 , . IV-11, IV-13, D-3
I-2, III(1)-6, III(1)-9, 111(2)-2 111(2)-5,111(3)-4, 111(4)-2, 111(5)-2 111(5)-5, 111(6)-5 A-2
iv, II-1 II-3 II-3
III(1)-5, 111(3)-2
iv, 111(6)-8, 111(6)-9,111(6)-10
111(6)-4
D
•
INDEX - 2
G
• H
•
INDEX - 3
SUBJECT
FINGER PRINT SYSTEM (FPS)
FINANCE ADMINISTRATOR
FITNESS CERTIFICATE
FORMS
(See also CSC) procurement local
FREE FROM INFESTATION (FFI)
FUNCTIONAL STAFF REVIEW
GENERAL CLINIC
GENERAL PHYSICAL EXAMINATION (CSC 61)
GENERAL POPULATION
HEALTH CARE CENTRE ACTIVITIES REPORT (CSC 30)
PAGE
v, 111-3, C-1
111(6)-8
111(6)-12
I-1, II-4, III-1, A-1
A-2, C-1 A-2
iv, III(1)-6, 111(6)-3, 0-1
A-1
D-2
III(1)-7, 111(6)-3 A-2
V, III(1)-9
IV-8
HEALTH CARE RECORD I-1, Active II-1, A-3 Current II-1 Dormant II-1, A-3 Inactive II-1, A-3 . Institutional II-1 Management Checklist A-1 Psychiatric (RPC/RTC records) II-1 Recall II-3, A-4 Storage II-2, II-3, A-3,
B-1 Temporary 11-3, A-4 Transfer II-2
HOSPITALIZATION
Hospital Admissions and Discharges sheet (CSC 484)
IMMUNIZATION Record of Immunization (CSC 378)
INACTIVE FOLDER Organization
III(1)-4, III(1)-9 D-2, D-3
I V-11
III(1)-5, IV-16 III(1)-10, A-2
V, II • 1 III-1
SUBJECT PAGE
INDEX - 4
I INFECTIOUS DISEASE IV-17 (See also FFI)
INFORMATION ACCESS AND RECORD MANAGEMENT 111-3
INJURY II-1, 11(2)-2, D-3 (See also ACCIDENT)
INMATE NUMBER V label C-5
INPATIENT CASE HISTORY (CSC 571) 111(6)-4
INSTITUTIONS II-2, B-1
INSPECTOR GENERAL A-1
INSTITUTIONAL HEALTH CARE RECORD vi, II-1, III-1, 111-4
INTER-INSTITUTIONAL TRANSFER (CSC 59) 111(6)-12
J
K
L LABORATORY REPORTS (CSC 49) 111(5)-2, 111(6)-3 A-1
M MAJOR PROBLEM LIST (CSC 57) 111-2, III(1)-2, (See also PROBLEM) III(1)-6, III(1)-9
, 111(2)-2, 111(2)-5 111(3)-4, 111(4)-3 111(5)-3, 111(5)-5 111(6)-5, A-2
MEDICAL AND HEALTH CARE SERVICES I-1, A-1, II-1
MEDICAL HISTORY (CSC 416) III(1)-4, III(1)-7 111(6)-3, A-2
MEDICATION (See also DRUG, PATIENT MEDICATION RECORD (CSC 55) Pill Parade vi PRN 111(3)-3
111(6)-7 STAT 111(2)-3, 111(3)-3
111(6)-7
1
•
INDEX - 5
SUBJECT PAGE
M
N
0
P
MENTAL DISTURBANCE (See also SUICIDE)
NON-ELECTIVE
OFFENDER DATA LABEL
OPERATION (See also SURGERY)
ORDERS (See DOCTOR'S ORDERS AND PROGRESS NOTES (CSC 471)
PATIENT AUTHORIZATION TO DISCLOSE PERSONAL HEALTH CARE INFORMATION (CSC 666)
PATIENT MEDICATION RECORD (CSC 55)
PHYSICAL EXAMINATION (See also GENERAL PHYSICAL EXAMINATION (CSC 61)
POMR (See PROBLEM)
PRE-MEDICAL EXAMINATION . (See also MEDICAL HISTORY (CSC 416)
PROBLEM (See also MAJOR PROBLEM LIST (CSC 57) Problem Oriented Medical Record (POMR)
PROGRESS NOTES (PEN 1167)
PROSTHESIS
PSYCHIATRIC
(See also MENTAL DISTURBANCE, SUICIDE) RPC/RTC records
PUBLIC ARCHIVES
POST RELEASE TREATMENT
PROCUREMENT (forms and supplies)
PROGRESS SUMMARY
III(1)-5, III(1)-9
111(6)-8
C-5
111(6)-6, IV-16
111(6)-13, A-2
111(3)-2, A-1
IV-10
vii
1-2
vi, I-1
111(6)-4
III(1)-6
II-1, III(1)-2, IV-13
vii,II-2
II-3
D-3
A-3, C-1
D-2 •
111(6)-3, IV-15
111(5)-4, A-1
III(1)-10, A-2
111(6)-4
111(6)-8
II-3, III(1)-7, III(1)-15
D-3 . 111(1) -7 111(6)-13 111(6)-13
111(6)-8
II-4
vii, 111(2)-2
IV-10
vii, I-2
INDEX - 6
- SUBJECT PAGE
RADIOGRAPHY' (See also X-RAYS) Radiography Requisition and Report - (CSC 51)
RECALL (SEE HEALTH CARE RECORD)
RECORD OF IMMUNIZATION (CSC 378)
RECORD OF TREATMENT ORDERS (Pen 1058)
REGIONAL MANAGER, HEALTH CARE SERVICES
REGIONAL PSYCHIATRIC TREATMENT CENTRE RECORDS (RPC/RTC) (See PSYCHIATRIC)
RELEASE
(See also DISCHARGE) Post Release Treatment Pre Release Physical Release of Medical, Dental Information Release of Psychiatric Information
REQUEST FOR MEDICAL SERVICES (CSC 552)
RULES OF RECORD KEEPING
SCREENING
SICK PARADE
SOAP (See also DOCTOR'S ORDERS AND PROGRESS NOTES - CSC 471)
STATISTICAL DATA
STORAGE (See HEALTH CARE RECORD)
SUICIDE (See also MENTAL DISTURBANCE)
SURGERY (See also OPERATION)
IV-1
III(1)-5, III(1)-9
III(1)-5, 111(6)-8
•
•
•
INDEX - 7
SUBJECT PAGE
V
X
Y
TAB COMPUCOLOR NUMERIC LABELS'
THERAPY (See also TREATMENT)
TRANSFER of records
TREATMENT (See also THERAPY)
Treatment Record (CSC 469) Treatment Centre Records (See Psychiatric)
TUBERCULOSIS (TB)
WARDEN Ass't Warden HCC
X-RAYS (See also RADIOGRAPHY) Dental
YOUNG OFFENDERS
111-3, C-1
IV-15
III(1)-15 II-2, II-3
111(2)-4
III(1)-5, III-(1)-11, IV-17
111(6)-8 I-4
III(1)-15
VII, 111-2
•
•
•