103 CMR 932.18 - Medical Records

(1) The county correctional facility shall develop a complete system for maintaining medical, dental, and mental health records of inmates. This shall include the maintenance of a separate medical record for each inmate committed or detained for more than 48 hours. All records shall be maintained in accordance with 105 CMR 205.000: Minimum Standards Governing Medical Records and the Conduct of Physical Examinations in Correctional Facilities.

(2) The medical record file shall contain, but not be limited to, the following items:

(a) the completed admission screening form;

(b) health appraisal data collection forms;

(c) prescribed medications and their administration;

(d) laboratory, x-ray and diagnostic studies;

(e) signature and title on each document;

(f) consent and refusal forms;

(g) release of information forms;

(h) place, date and time of health encounters;

(i) discharge summary of hospitalizations;

(j) health service reports (e.g., dental, psychiatric and other consultations); and,

(k) all findings, diagnoses, treatments, dispositions. (M.G.L. c. 127, § 17).

(3) The county correctional facility shall ensure that the method of recording entries in the medical record, and the form and format of the record, are approved by the health authority.

(4) Written policy and procedure shall govern the confidentiality of the medical record and require that, at a minimum:

(a) the active health record is maintained separately from the confinement record;

(b) access to the health record is controlled by the health authority, and that only those persons who need access to the record in order to provide medical services to the inmate or fulfill statutory obligations, and those persons specifically authorized by the inmate to see the record shall have access to the information in them; and,

(c) the health authority shall share with the Sheriff/facility administrator information regarding an inmate's medical management, security, and ability to participate in programs; and

(d) Human immunodeficiency virus (HIV) test information shall be released only with the inmate's written consent, or as otherwise provided under Massachusetts General Laws.

(5) The county correctional facility shall provide for the inspection of a medical record by the subject inmate, by his attorney or by any other person upon written authorization from the inmate. In accordance with 105 CMR 205.505, the inmate's signature on the written authorization shall be witnessed by a county correctional facility staff person.

(6) Written policy and procedure shall govern the transfer of health records and information, and shall include the following requirements:

(a) a copy of the medical record or a summary sheet shall be forwarded with the inmate upon transfer to another correctional or health care facility. Any portion of the record, which is not reasonably completed at the time of transfer, shall be completed and a copy delivered to such facility within 72 hours of the transfer; and,

(b) medical record information shall also be transmitted to specific and designated physicians or medical facilities in the community upon the written authorization of the inmate.

(7) The facility shall provide for the maintenance of inactive medical records, in accordance with jurisdictional authority.

Notes

103 CMR 932.18