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(1) The Health Authority shall design and implement written policies and procedures for the maintenance of medical and dental records for use in correctional facilities which are:
(i) documented accurately, legibly, and in a timely manner; and
(ii) readily accessible to health care personnel.
(2) Records for inmates who are treated at the hospital shall comply with the legal requirements of the hospitals' accrediting agent(s).
(b) Format and Contents.
(1) The Health Authority shall approve uniform medical and dental forms for the recording of health information at all Department of Correction facilities.
(2) A health record shall be established and maintained for each inmate. At a minimum, the health record file shall contain, but not be limited to, the following:
(i) the completed intake screening form, as described in 40 RCNY § 3-04(b);
(ii) a problem list;
(iii) place, date, time, and the type of health service provided at each clinical encounter;
(iv) all findings, diagnoses, treatments, dispositions, recommendations, and summary of instructions to inmates;
(v) prescribed medications, their administration, and the duration;
(vi) original or copies of original laboratory, x-ray, and other diagnostic studies;
(vii) signature and title of each health care provider shall accompany each chart note; (viii) completed consent and refusal forms;
(ix) release of information forms signed by the inmate;
(x) special diets and other specialized treatment plans;
(xi) clinical and discharge summaries when an inmate is treated outside of Department of Correction facilities;
(xii) health service reports of medical and dental treatments, examinations, and all consultations pertaining to such services; and
(xiii) flow sheets for all infirmary or chronic patients.
(3) The health record shall accompany each inmate whenever he or she is transferred to another New York City Department of Correction institution. The health record, or a copy of the record, or pertinent sections of the record shall accompany each inmate whenever he or she is treated in a specialty clinic within a Department of Correction facility upon request of the specialty clinic physician.
(4) When an inmate is treated at a specialty clinic in a municipal hospital or other off-site health care facility, a detailed consultation request containing significant data, lab results and all relevant medical history shall accompany each inmate. When specialists at any off-site facility require the complete medical record, there shall be a written procedure in place to allow for the confidential transfer and return of this record or a copy of the record.
(c) Retention of Institutional Records.
(1) At a minimum the Health Authority shall be responsible for the following:
(i) safeguarding all health records from loss, tampering, alteration, or destruction;
(ii) maintaining the confidentiality and security of health records;
(iii) maintaining the unique identification of each inmate's health record;
(iv) supervising the collection, processing, maintenance, storage, timely retrieval, distribution, and release of health records;
(v) maintaining a predetermined, organized health record format; and
(vi) retention of active health records and retirement of inactive health records.
(2) Active and inactive health record files shall be retained according to all applicable laws.