Perf-Based Stds, Juvenile Correctional Facilities, 5th Ed_DEC 2024

Part 5: Care

The health authority approves the method of recording entries in the records, the form and format of the records, and the procedures for their maintenance and safekeeping The health-record is made available to and is used for doc umentation by all qualified health care professionals and health care practi tioners Comment : The receiving-screening form should become a part of the record at the time of the first health encounter. Records may be maintained electronically.

Protocols : Written policy and procedure.

Process Indicators : Health-records; observations; interviews.

Inactive Health Records 5-JCF-5C-34 (Ref 4-JCF-4C-33)

Inactive health-record files are retained as permanent records, in accordance with state and federal law. Health-record information is provided to specific and designated health care practitioners or medical facilities in the communi ty only on the written request or authorization of the juvenile’s parent, guard ian, or legal custodian

Comment : None.

Protocols : Written policy and procedure.

Process Indicators : Completed facility-request and authorization forms; health- record entries; observations; interviews.

88 Juvenile Correctional Facilities, Fifth Edition