Health Records

Home Standards Q&A Health Records

In our facility, each of the major disciplines (medical, dental, mental health) keeps its own records separately. Is a unified health record required for accreditation?

In the 2018 manuals, standard A-08 Health Records does not require a unified health record for accreditation, but it is certainly recommended to facilitate continuity of care. Allowing each major discipline to maintain its own records is not only less efficient, but also less effective in that it allows more room for error.

While we recommend a unified health record, if the facility chooses to maintain records separately by discipline, this is acceptable for accreditation purposes, provided that the following criteria are met:

Pertinent basic information must exist in all three charts. For example, all three charts would have to list current problems, allergies and medications. We recommend establishing a mechanism to ensure that basic information with respect to treatment in progress is provided by each discipline to the other disciplines.

Other aspects of the management of the health record would apply to all three charts. For example, all three charts would have to observe the standard with respect to confidentiality of health records, transfer of the health records or summaries, reactivation of records and retention of the health records.

— From CorrectCare Volume 32, Issue 4, Fall 2018

We are looking at long-term health record storage options for inactive inmates, such as those who have been paroled or discharged from the system. I do not want to be in violation of any NCCHC standards. Is it permissible to store sealed inactive inmate health records with DOC records in a storage building? The storage building would have minimal access and anyone accessing the building would have training in confidentiality.

Yes, this is permissible. Standard H-02 Confidentiality of Health Records requires that health records stored in the facility are maintained under secure conditions separate from correctional records, and that access to health records and health information is controlled by the responsible health authority (compliance indicators #1 and #2). However, the standards do not specify how you store health records off-site. Rather, H-04 Management of Health Records requires that you have a system for the timely reactivation of records when requested by a treating health professional. You may want to check local or state laws regarding the confidential storage of inactive health records before implementing the system described.
— From CorrectCare Volume 27, Issue 2, Spring 2013

We have an electronic health records system. Will NCCHC be updating accreditation requirements concerning electronic signatures and forms?

The Standards for Health Services already address electronic health records (EHR). In essential standard H-01 Health Record Format and Contents, Compliance Indicator 3 states, “If electronic records are used, procedures address integration of electronic and paper health information.” The Recommendations section adds that such systems “should protect access and provide security… by the use of passwords. Procedures for ‘down time’ and regular backups should be in place.”

Basically, everything that is required of a hard record is also required of the electronic record. Using standard H-04 Availability and Use of Health Records as an example, if sick calls are entered directly into the EHR, health staff must be able to access the record in the sick-call room. As with the hard records, forms may be facility-specific as long as they provide the required documentation. If it is legal in your state, NCCHC does accept electronic signatures of health staff.

— From CorrectCare Volume 20, Issue 4, Fall 2006

Do the NCCHC standards require that a jail start a health record for everyone who is admitted?

No. Each inmate admitted must have a receiving screening completed and documented (standard J-E-02 Receiving Screening). Most jails keep the receiving screening documents in a general file for easy access or future reference should the inmate be readmitted. However, a health record must be created if any health intervention is provided after the receiving screening (J-H-01 Health Record Format and Contents). A copy of the receiving screening forms should be included in this record.

— From CorrectCare Volume 19, Issue 4, Fall 2005

My state’s department of corrections uses prison beds in another state. What is NCCHC’s stance on integrating medical records from one state into another state system? We had been placing all medical information (summaries of patient care received from the other state) in the medical file’s miscellaneous section and all mental health information in the mental health section. The DOC says we should sort all information from the other state—e.g., progress notes, physician orders, labs—into the current chart. We have no problem doing this, but feel it might be confusing as to what took place where.

This issue is not addressed in NCCHC’s standards. Thus, you can make an internal decision about the most useful way to organize the chart for your health staff and have the state medical director issue the directive. NCCHC accreditation surveyors would be concerned that documentation from another system was clearly labeled as such and readily available for reference by the health staff of your system. How you choose to do that, though, is up to your system.

— From CorrectCare Volume 17, Issue 2, Spring 2003

Health Records

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