Utah Department of Administrative Services

Division of Archives & Records Service

Dept. of Corrections Schedule 8: Offender Medical Records

 

 

8-1. ALCOHOL AND SUBSTANCE ABUSE MONTHLY STATUS REPORT

This report tracks the number of residents enrolled or discharged from the program. Includes the number of inmates and parolees in the program, the number admitted and discharged, the location where the treatment occurs, attendance count and the number in the aftercare program.

RETENTION

Retain for 2 years and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Public.

Approved: 10/1999

 

8-2. ALCOHOL AND SUBSTANCE ABUSE RECORDS

Records of diagnosis and treatment for clients charged to the care of the Alcohol and Substance Abuse Treatment Program at the State Prison or Adult Probation and Parole. Information includes diagnostic records, consent forms for the release of information, treatment records, and attendance records of treatment sessions.

RETENTION

Retain by agency for 10 years after released from prison and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(b) (2008).

Approved: 10/1999

 

8-3. CLINICAL SERVICE ADMISSION LOG

This log is used to monitor the completion of medical screens for inmates entering into the prison. Information includes the inmate name and number and the date of admission, date of mental health exam, date of physical exam, date of dental exam, date of Human Immunodeficiency Virus test (HIV), etc. All medical data is entered into the inmate's medical record.

RETENTION

Retain by agency for 1 year and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(b) (2008).

Approved: 04/2000

 

8-4. HUMAN IMMUNODEFICIENCY VIRUS (HIV) CONTROL PROGRAM FILES

Program files related to the operations of the HIV/AIDS Control Program. Includes disease control and patient information regarding AIDS and HIV, narratives, summary data reports, and other general program information.

RETENTION

Retain by agency until updated or superseded and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Exempt: UCA 26-25a-101.

Approved: 10/1999

 

8-5. INMATE MEDICAL RECORD

Documents all medical procedures conducted on inmates. Information includes physician orders, prescriptions, pharmaceutical records, progress notes, lab reports, prescription/treatment history, intake history records, consultation reports, medical history, psychiatric notes, psychological notes, x-rays, health care request forms, medical clearance forms, memorandums, record request forms, dental examinations/treatment, optometry examinations, audiology reports, physical therapy treatments, psychological assessments, psychological histories, discharge summary, mental health treatment plans and psychological test results.

RETENTION

Retain by agency for 10 years after released from prison and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(a) (2008).

SUGGESTED SECONDARY CLASSIFICATION

Controlled: UCA 63G-2-304 (2008)

Approved: 04/2000

 

8-6. LAB TEST LOG BOOKS

This series documents when a lab test is requested to facilitate diagnosis. The log is maintained to determine the status of all tests sent out for processing and to verify medical services costs. The log contains the resident's name, number, test requested and the date the test was ordered.

RETENTION

Retain for 3 years and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(b) (2008).

Approved: 10/1999

 

8-7. PRESCRIPTION ISSUANCE FILES

These files document the issuance of prescriptions to residents. The information is also used to prepare pharmacy requisitions. Information includes resident's name, number, drug issued, dosage, instructions, date prescribed, and practitioner's signature.

RETENTION

Retain for 2 years and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(b) (2008).

SUGGESTED SECONDARY CLASSIFICATION

Controlled: UCA 63G-2-303 (2008)

Approved: 10/1999

 

8-8. UNIVERSITY MEDICAL CENTER SCHEDULED APPOINTMENTS

These records are used to document medical appointments for inmates who require special medical care. Information includes appointment date, inmate name and number, clinic name and address, doctor, and return time.

RETENTION

Retain by agency for 3 years and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Public.

Approved: 10/1999

 

8-9. X-RAY FILES

These records are used by the prison physicians for diagnosis of the medical condition of the residents and for preventitve healthcare. The files contain the x-ray films, date and x-ray file number.

RETENTION

Retain by agency for 10 years after inmate's release from prison and then destroy.

SUGGESTED PRIMARY CLASSIFICATION

Private: UCA 63G-2-302 (1)(b) (2008).

Approved: 04/2000