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Policy 728Santa Ana Police Department Custody Manual Copyright Lexipol, LLC 2024/02/21, All Rights Reserved. Published with permission by Santa Ana Police Department***DRAFT*** Management of Health Records - 1Management of Health Records 728.1 PURPOSE AND SCOPE The purpose of this policy is to establish a uniform manner of maintaining the active health records of incarcerated persons for easy accessibility during clinical treatment, and the storage methods for inactive health records. This policy also addresses practices that will ensure the confidentiality of health record information by separating it from custody records. 728.1.1 DEFINITIONS Definitions related to this policy include: Protected health information - Information that relates to the incarcerated person's past, present, or future physical or mental health or condition, the provision of medical care to the incarcerated person, or the past, present, or future payment for the provision of health care to the incarcerated person (45 CFR 160.103). 728.2 POLICY It is the policy of this department to maintain the confidentiality of incarcerated persons' protected health information. Incarcerated person health records will be maintained separately from custody records and under secure conditions, in compliance with all local, state, and federal requirements. The Responsible Physician or the authorized designee will establish standardized facility procedures for recording information in the file and for the control and access to incarcerated person health records. Incarcerated workers shall not have any access to incarcerated person health records. 728.3 INITIATING A HEALTH RECORD Following the initial medical screening process, the qualified health care professional shall initiate a health record for each incarcerated person. The Responsible Physician shall be responsible for developing and implementing procedures for standardized record formatting (15 CCR 1205 et seq.). 728.4 CONFIDENTIALITY OF AN INCARCERATED PERSON'S HEALTH RECORDS Information regarding an incarcerated person's health status is confidential. Active health records shall be maintained separately from custody records. Access to an incarcerated person's health record shall be in accordance with state and federal law (Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191 and the implementing regulations) (15 CCR 1205). The incarcerated person's protected health information may be disclosed, with the incarcerated person's written authorization, to any person so designated. A fully completed authorization for release and/or a disclosure of protected health information form shall be required prior to disclosure based upon informed consent (15 CCR 1205). Santa Ana Police Department Custody Manual Management of Health Records Copyright Lexipol, LLC 2024/02/21, All Rights Reserved. Published with permission by Santa Ana Police Department***DRAFT*** Management of Health Records - 2The incarcerated person's protected health information may be disclosed by the qualified health care professional without the incarcerated person's authorization under certain circumstances and when approved by the Responsible Physician or the authorized designee. Those circumstances include: (a)To known qualified health care professionals who are members of the health care team responsible for the incarcerated person's care. (b)To custody staff regarding incarcerated persons as reasonably necessary to protect the safety, security, and good order of the facility. Examples may include information that the incarcerated person may be: 1.Suicidal. 2.Homicidal. 3.A clear custodial risk. 4.A clear danger of injury to self or others. 5.Gravely disabled. 6.Receiving psychotropic medications. 7.A communicable disease risk. 8.In need of special housing. (c)To the local public health officer when an incarcerated person is part of a communicable disease investigation. (d)Pursuant to a court order or valid subpoena duces tecum, accompanied by satisfactory assurance that the incarcerated person has been given notice and an opportunity to file an objection or efforts have been made to secure a protective order as required under HIPAA (45 CFR 164.512). (e)To a law enforcement officer for purposes of a criminal investigation, to avert a serious threat to the health or safety of any person or to fulfill mandatory reporting requirements. (f)To a law enforcement officer when the incarcerated person has died as a result of criminal conduct. The incarcerated person's limited protected health information may also be disclosed to a law enforcement officer for purposes of identifying or locating a suspect or when the incarcerated person is a victim of a crime. When reasonably possible, the approval of the Jail Administrator should be obtained prior to disclosure. Attorneys requesting health record information regarding an incarcerated person shall be advised that an authorization for release and/or a disclosure of medical information form signed by the incarcerated person is required. Family members may be informed of the incarcerated person's custody status and whether the incarcerated person is receiving medical care. Family members requesting additional information Santa Ana Police Department Custody Manual Management of Health Records Copyright Lexipol, LLC 2024/02/21, All Rights Reserved. Published with permission by Santa Ana Police Department***DRAFT*** Management of Health Records - 3must provide a proper authorization for release and/or a disclosure of medical information form signed by the incarcerated person. The Jail Administrator, in consultation with the Responsible Physician, shall designate personnel who will be responsible for reviewing all requests for access to medical records and who will propose related policies and procedures and other activities designed to facilitate proper documentation of health care and access to records. 728.4.1 ADDITIONAL STATE PRIVACY PROTECTIONS The health services administrator and Responsible Physician or the authorized designee shall ensure that privacy protections comply with state law requirements regarding privacy and confidentiality applicable to the specific type