Procedure - Medical Records

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Purpose
1.	Process
2.	Medical record entries
2.1	Medical letters/hospital discharge summaries
2.2	Blood screening results
2.3	Injury reports
2.4	Medical charts leaving the health centre
3.	Medical chart transfer
4.	Nursing Intervention Register
5.	Requests for medical information

Purpose

To ensure medical records comply with ethical and legal standards of documentation and Queensland Corrective Services (QCS) standards.

1. Process

Medical history, assessments and treatment should be clearly and accurately documented and identifiable in the offender's medical chart, along with clear identification of the person and designation of the signatory.

It is essential, both for the ongoing clinical management and legal and administrative reference, that clinical staff maintain the highest standard of recording.

2. Medical record entries

Each relevant clinical detail is to be recorded and must comply with the following-

1. medical record entries must be entered under a date and time;
2. the recorder's handwriting in the medical notes must be legible;
3. the recorder is to sign at the end of each set of notes. The signature is to be followed by a printed or stamped name of the signatory;
4. the status of the recorder must be clearly noted after the name, eg. RN and;
5. black ink only must be used for recording in the medical records.

Medical charts must comply with the QCS format, and filing contained therein should be placed appropriately. Maintaining the charts in the prescribed format is the responsibility of each facility. All documentation in medical records and official records are the property of QCS and comply with the standard format to enable all staff within QCS to easily access information.

2.1 Medical letters/hospital discharge summaries

After notation by the visiting doctor they should be filed in the Medical Chart after “Outpatient Appointments” or “Correspondence".

2.2 Blood screening results

On receipt of the pathology slips-

1. notation of result is made on the “Blood Testing / Immunization Record”;
2. result slip is filed in “Investigations” - in chronological order (later tests in front). Results must be noted by the requesting doctor prior to filing; and
3. results for offenders discharged are filed in the medical records or forwarded to Medical Records for filing while result slips of offenders who have been transferred are forwarded to the facility of transfer.

2.3 Injury reports

Original is forwarded to Health and Safety Officer. Copy is filed in Medical Chart in the section “Progress Notes”.

2.4 Medical charts leaving the health centre

Appropriate recording must be maintained showing where the file has been forwarded to and for what purpose, eg. CSIU, FOI.

3. Medical chart transfer

Offenders transferred to other facilities must have their medical records and X-Rays sent with them except to low security facilities without clinical nurses.

Medical Charts that leave the facility must be in a sealed envelope with-

1. “Medical-in-Confidence” stamped or written across the top;
2. the offender's name;
3. the name of receiving facility; and
4. the name of forwarding facility or in the locked grey bags provided.

Offenders transferred to hospitals for appointments or admission should only have administrative form - P96 Medical Transfer sent. It is also appropriate to include photocopies of other required documentation, if necessary. The medical chart must not be forwarded outside of the QCS jurisdiction.

4. Nursing Intervention Register

All verbal requests requiring health professional assistance which are forwarded to the health centre by the offender or other persons on behalf of the offender must be documented, regardless of outcome. The health centre's Nursing Intervention Register should note details of the request including date, time and any action/inaction. All requests requiring health professional assistance must also be documented in the offender's medical file under their progress notes.

5. Requests for medical information

Requests for medical information should be directed through the QCS Consultant or Senior Adviser, Health and Medical Services. Medical Charts remain the property of QCS and requests for information or sighting of same can be made by the offender through the Freedom of Information Officer.

F P Rockett
Director-General