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ORANGE COUNTY JAIL <br />144 E. Margazet Lane <br />Hillsborough, North Carolina 27278 <br />POLICY #: 4.14 <br />POLICY TITLE: MEDICAL RECORDS <br />DATE: JULY 1, 200.3 <br />RELATED N.C. <br />STANDARDS: 240.3 (a) (8); 3201(b) (6); .3208 <br /> <br />PAGE 1 OF 3 <br />POLICY STATEMENT: In order to protect the privacy of inmates and to comply with <br />state and federal statutes and case law, inmate medical records will be filed and maintained in a <br />secure azea separate from inmate confinement records, Authorized medical professionals shall <br />be responsible for the maintenance of inmate medical records and will be the only individual <br />authorized access to izunate medical records. <br />SPECIFIC PROCEDURES: <br />1, Inmate Medical Records: <br />A. During the admission process, the admitting officer will ensure that a medical <br />record is established for each inmate confined to the facility. A copy ~f the inmate's <br />"Preliminazy Health Screening Form" and "Inmate Medical Screening Report" will be <br />included in the medical record and another in the inmate's confinement record. <br />B. The "Preliminary Health Screening Form" and "hrmate Medical Screening <br />Report" should be the only medical documents filed in the inmate's confinement record.. <br />No part of an inmate's medical file should be made a part of his/her confinement record. <br />Copies of any instructions written by an attending physician for ,jail officers to follow <br />(e.g., inmate medication schedules; special housing authorizations; etc.) may also be filed <br />in the inmate's confinement record inasmuch as officer's must and are required to have <br />access to this information. HOWEVER, UNDER NO CiRCUMSTTANCES WILL <br />ANY MEDICAL INFORMATION OR DOCUMENT THAT MAY CONTAIN <br />INFORMATION RELATIVE TO AN INMATE'S DIAGNOSIS BE FILED IN AN <br />INMATE'S CONFINEMENT RECORD. <br />C Should an inmate disclose information during the admission process that may <br />suggest that he/she is infected with any disease or condition deemed confidential either <br />by state or federal statute, case law, standard, or regulation, the officer will ensure that <br />this information is recorded on a separate "Preliminary Health Screening Form" and <br />"Inmate Medical Screening Report' and filed only in the inmate's medical record (see <br />also, Orange County Jail Policy, 2.11, "Preliminary Health Screening"). <br />