Series Title (Agency Series #): Description, Retention (Legal Citation)
Accreditation Records (DOH30-001): Series documents process by which the National Commission on Corrections Health Care (NCCHC) provides accreditation to county correctional facility clinics and audits them for compliance. The accreditation process is on a three-year cycle. Records include clinic policies and procedures, copies of site logs and schedules, accreditation visit reports, annual accreditation reports (non-visit), correspondence, and related records.
Retention: Retain 20 years. (2009-0001/025)
Adult Inmate Medical Case Records (DOH30-002): Records documenting medical, mental health, and dental services provided to inmates I Multnomah County correctional facilities. Records may include inmate management cards, medication charts, problem lists, patient parameter, flow sheet, dental treatment records, x-rays, health services history form, information release authorizations, progress notes, screening forms, police reports, case correspondence, and related records.
Retention: Retain 6 years after inmate released. (MOAR 166-150-0065(20))
Billing Records (DOH30-003): Documents billings for inmate services provided through Corrections Health clinics. Used to input information into the Sheriff's Warrant Information System in order to deduct payments from inmate accounts. Include billing encounter forms and medical service requests. Information includes client name and identification number, date of service, type of service, type of provider, provider's initials, data entry, and clerk's initials.
Retention: Retain 6 years. (45 CFR 164.530(j))
Client Incident Reports (DOH30-004): Documents any incident involving Corrections Health staff and inmates in their care. Reports show client name, facility and case number, date and time of incident, description of the incident, action taken by staff, and dated signature of reporting staff member.
Retention: Retain 10 years. (2009-0001/026)
Clinic Correspondence (DOH30-005): Correspondence, memoranda, and similar records which document and add significant information to the division or primary functional responsibility of the clinic. Includes letters sent and received, memoranda, notes, and other records related to specific programs or primary functions.
Retention: Retain 7 years. (MOAR 166-150-0005(8))
Clinic Logs (DOH30-006): Documents client visits to the clinic and services provided. Includes infirmary log, EKG log, transport log, phone verification log, release of information log, isolation check log, emergency cart check log, syringe and needle sign-out log, and related logs. Information includes individual entries showing inmates name and number, date and time of admission, services provided, and date and time released.
Retention: Retain 7 years. (2009-0001/027)
Clinic Procedures and Protocols (DOH30-007): Series documents review, assessment, development, and authorization of division clinic procedures and protocols. Records may include authorizing bulletins and advisories, mission and goal statements, manuals, and final policy statements and directives. Information often includes policy and identification, narrative description, authorization information, and related information.
Retention: Retain 20 years after superseded. (MOAR 166-150-0005(25))
Controlled Substance Inventory (DOH30-008): Documents all Class 3-5 controlled substances received, dispersed, and destroyed by the pharmacy. Inventory records include listing of controlled substance by type, date received, date dispersed, person dispersing drug, and periodic inventories of stock.
Retention: Retain 3 years. (21 CFR 1304)
Daily Prescription Report (DOH30-009): Documents all prescriptions filled in each day. Includes two separate listings; one for controlled substances (Classes 3-5) and one for other prescriptions. Report lists includes client's name, prescription description, and person filling prescription.
Retention: Retain 3 years. (MOAR 166-150-0065(18))
Entry Progress Forms (DOH30-010): Records documenting medical, mental health, and dental services provided to inmates in Multnomah County correctional facilities. If enough EPF's have been created for an inmate, a case file will be generated. Records include inmate management card and entry progress from. Information includes Inmate name, date of birth, information about mental and physical condition, health problems/factors, allergies, registered nurse signature, date and time admitted, and referral information.
Retention: Retain 7 years after inmate released. (MOAR 166-150-0065(20))
Juvenile Medical Case Records (DOH30-011): Records documenting the medical, mental health, and dental treatment of juveniles held at the juvenile detention facility. Screen and release files are files maintained on juveniles who were screened upon entering custody, but to whom no services were provided. Records may include problem list, progress notes, medication charts, treatment records, lab results, test results, x-rays, health assessments, communicable disease screening, inmate worker forms, special diet orders, treatment consent/refusals, information release forms, mental health evaluations, screenings, case correspondence, and related records.
Retention: Retain 6 years after last service. (MOAR 166-150-0065(20))
Pharmacy Purchasing Records (DOH30-012): Records documenting orders, authorizations, and evidence of receipt of the purchase of drugs and supplies by correctional facility clinic pharmacies. Includes purchase orders and requests, purchase authorizations, requisitions, controlled substance invoices and delivery receipts, and related records.
Retention: Retain 3 years. (MOAR 855-043-0130(5B))
Prescription Records (DOH30-013): Documents prescriptions filled by the correctional facility clinic pharmacies for inmates. Prescriptions show client's name, description of item prescribed, date prescribed, and signature of person prescribing item.
Retention: Retain 3 years. (MOAR 166-150-0065(18))
Provider Schedules (DOH30-014): Documents providers' work schedules, patients they saw, and services provided. Includes a variety of schedules for nurses, interpreters, doctors, counselors, and technicians. Schedules show provider's name, date, assigned shift, people they saw, and services provided. Also includes daily schedule of patients seen.
Retention: Retain 6 years. (2009-0001/028)
Statistical Reports (DOH30-015): Documents clinic activities for research and reference. Compiled and maintained for internal reference as well as to comply with accreditation requirements. Includes annual statistical report for Corrections Health, monthly clinic statistical reports, and daily statistical worksheets and forms. Information includes type of clinic visit, services provided, average length of stay, specialty referrals and procedures, cancellations, and historical comparisons.
Retention: Annual report: retain permanently; monthly report: retain 6 years; worksheets and forms: retain 1 year. (MOAR 166-150-0005(31))