Health Records
What is the Operating Procedure number for Health Records
701.3
What is the Operating Procedure number for Access to Health Services?
720.1
What is the Operating Procedure number for Medical Screening, Classification, and Levels of Care?
720.2
1. Date
2. Time
3. Medication prescribed
4. Dosage
5. Directions for administration with indication
6. Duration of order
7. Prescribers name
Can unsaturated bandages, gauze, or cotton swabs be placed in regulated medical waste/biohazard containers?
No, unless they are saturated with human blood or would release human blood/body fluids, or caked materials
24 hours
Medical request should be triaged within 24 hours by a Registered Nurse and seen by an RN within 72 hours (96 hour on weekends)
Health appraisals must be completed in how many days after arrival at the facility?
1. 14 days after arrival for inmates with identified significant health care problems.
2. 30 days after arrival for inmates without significant health care problems.
List at least 3 medications that are not permitted for KOP
1. Bulk Forming Laxative Powders (Reguloid/Metamucil)
2. Controlled Substances
3. Imiquimod (Aldara; Zyclara)
4. Injectables
5. Loperamide
6. TB medications
7. 340b or high cost medications
8. Psychotropic medications unless authorized by Chief Pharmacist or designee in writing, or as approved at CCAP
9. Restricted Inhalers (Respirmat, Handihaler, Twisthalers)
10. Skeletal Muscle Relaxants
11. Warfarin
12. Restricted medications by Prescriber, Health Authority or Designee
When an inmate is transported to the ED via EMS how often should an assessment and vital signs be obtained?
Every 5 minutes
Health Care Practitioner orders must be all noted in red ink with what items? (4)
1. First Initial
2. Last name
3. Title
4. Date
When an urgent referral is made the patient should be seen by a medical provider within ___ hours of the referral. Routine referrals should be seen within _____.
When an urgent referral is made the patient should be seen by a medical provider within 72 hours of the referral. Routine referrals should be seen within 2 weeks.
Changes in the medical classification or location code will be noted in what 3 places:
1. VACORIS
2. Health Services Complaint and Treatment Form
3. Problem Sheet
When removing a medication from an Emergency Box or Stat Box what must be present?
What is the Operating Procedure number for Emergency Medical Equipment and Care? AND What is the Operating Procedure number for Infectious Waste Management and Disposal?
1. Emergency Medical Equipment and Care: 720.7
2. Infectious Waste Management and Disposal 740.2
When an inmate is released from DOC institution, the health record will remain at the last facility of assignment for how long?
3 months
How many days a week should clinical services be available to inmates.
All admissions and discharges to Convalescent Care (MOU) require a prescribers order, and the prescriber will see the inmate by when?
The prescribers next scheduled working day.
72 hours
Once the regulated waste is generated (the container has been sealed for transport), it can be only held at the facility for what time period before requiring transport?
15 days if refrigerated
List the 6 items that should be labeled on the cover of the health record folder
1. Inmate name
2. DOC Number
3. Allergies
4. Interstate Compact when relevant
5. The volume #
6. Medicaid Approved: Blue DMAS Identifier
When an "at risk" inmate is placed in a Restorative Housing Unit what is completed? And how often is this completed?
1. At Risk Physical Screening (vital signs to include weight)
Completed no less than every 14 days
Newly received inmates should receive the following Labatory tests (13): (This includes female test too)
1. RPR Syphilis
2. CBC with diff
3. CMP
4. Urine Pregnancy
5. Urine Chlamydia and Gonorrhea (Males)
6. Urinalysis
7. Cervical cytology (PAP test) and testing for Chlamydia and Gonorrhea (females)
8. TST
9. Chancroid, if symptomatic
10. Granuloma inguinale, if symptomatic
11. HIV
12. Hepatitis C
13. Hepatitis B Virus Antibody and Hepatitis B Surface Antigen
Controlled Substances must be counted and documented on the Count Sheet when?
At each nursing shift change by the nurse going off duty and the nurse coming on duty
Three years