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All medical encounters will be entered into the medical record using a <br /> narrative, pathways or S.O.A.P. format. The medical record will contain the <br /> following elements and all laboratory reports, consult reports, discharge <br /> summaries, and diagnostic studies will be reviewed and initialed by the <br /> physician before placement in the medical record. <br /> 1. Master Problem List (if a chronic condition patient); <br /> 2. Receiving Screening form; <br /> 3. Admission Data/History and Physical Assessment form; <br /> 4. Physicians' Orders form; <br /> 5. Progress Notes; <br /> 6. Laboratory studies; Diagnostic studies; Dental records; <br /> 7. Psychiatric and psychological reports; <br /> 8. Consultant's reports; x-ray reports; <br /> 9. Medication Administration Records; <br /> 10. Consent forms; Discharges summaries; <br /> 11. Release of Responsibility and Authorization for Release of <br /> Information Forms; <br /> 12. Sick Call Request forms; <br /> 13. Specialized treatments plans; <br /> 14. All other relevant and medically related materials; <br /> 15. Transfer forms <br /> When an inmate is reincarcerated, the prior record, if one exists, will be <br /> reactivated and reviewed by the medical staff. The inmate will have one (1) <br /> medical record that contains a record of all medical services that are <br /> rendered. <br /> All forms must be signed and dated appropriately. <br /> Confidentiality of Health Records <br /> HIPAA regulations apply to any protected health information such as <br /> information that concern's a person' social security number, date of birth, <br /> physical or mental health, healthcare, or payment information that could be <br /> used to identify an individual. That information must be blocked from a <br /> disclosure of such information. While individuals are in a correctional <br /> institution, SHP can use or disclosure an inmate's protected health <br /> information to the medical unit of another correctional institution for the <br /> following reasons: <br />