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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

/j 1h

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 •

•

•

• 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

•

•

1•••• •

C/3 SIN

■QC

•

•

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

•

•

•

1=1 .1= C13

M * -

•

•

•

•

•

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

•

•

•

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)


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)


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)


•

•

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)


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.


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.


•

•

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


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..


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


•

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


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)


•

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


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.




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).


•

•

Service Servir COIUM100 ■ 10

Canna

TREATMENT FICHE DE RECORD TRAITEMENT


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


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


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



Inpatient Case History (CSC 571)


(Check for drug allergies and/or intolerances.)


• ONE - Maintained in dispensary, transferred to the Institu-

tional Health Care Record (Section 3) at the end of the

month.


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


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..


_

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 —


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


HEALTH CARE RECORD • Contents:


•

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






COPIES AND DISTRIBUTION: TWO Original - Institutional Health Care Record

(Section 4)

Yellow - Consultant retains


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.


MEDICAL MEDICAL CONFIDENTIAL CONFIDENTIEL.


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


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


Major Problem List (CSC 57) COPIES AND DISTRIBUTION: ONE - Institutional Health Care Record (Section 5)


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.



MEDICAL

CONFIDENTIAL

TO BE OPENED

BY


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.


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



COPIES AND DISTRIBUTION: TWO Original - Institutional Health Care Record

(Section 5)

Yellow - Radiologist retains.




MEDICAL

CONFIDENTIAL

TO BE OPENED

BY


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 CONFIDENTIEL


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


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:



Dental Record (CSC 133)





Once all tasks are completed and documented on the corres-

ponding forms, this form may be destroyed.


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.


Policy and Procedures Manual 301, 404 FORMS INTERRELATED: General Physical Examination (CSC 61)





Patient Medication Record (CSC 55)




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.


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:


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.


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:


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.


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.


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

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1+ ADMISSIONS AND DISCHARGES

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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

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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 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.

•

•

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

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2 ROUTINE PHYSICAL EXAMINATIONS - EXAMENS MEDICAUX COURANTS

; ke

3 BED CARE - INFIRMERIE

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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

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O•oe• no. qa t L...1•es "OG

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5 THERAPEUTIC PROCEDURES - THERAPIES 6. LABORATORY PROCEDURES - EXAMEN DE LABORATOIRE

A

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; B

8 SUFIGICAL OPERATIONS INTERVENTIONS CHIRURGICALES

F../7•.; •a. •. ', etc • ■• ^C. at a" i0••• ■••• CSC. •oe R .O..•••• o• SCC -• C5C

A i S

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10 INFECTIOUS DISEASES 1/3r00m/tin. - MALADIES INFECTIEUSES IDerent Nor. Fob'« don repo-on/

s

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• 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


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


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



•

• 4. Procurement of Inmate Number Labels and Offender Data Labels



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 temporary 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

•

•

•

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