a) The Center will develop a health record
system that provides for consistency, confidentiality, storage and security of
records for documenting significant student health information and the delivery
of health care services. (See Problem-Oriented Medical Record System and
Medical Record Management Guidance in Section
2200.50(c).)
1) The Center must maintain a single
confidential medical record for each student receiving services. The medical
record must be kept in a physically secure manner that protects it from
unauthorized use.
2) The Center's
health records must be maintained in a manner that is current, detailed,
confidential and organized, and promotes effective student care.
3) The Center may separately maintain medical
records needing a higher level of confidentiality, including, but not limited
to, mental health, substance abuse, family planning and HIV testing records,
provided that there is an effective cross referencing system. Access to such
records must be restricted to authorized personnel.
4) The Center must have written policies that
address exchange of health information verbally and/or faxed to insurers,
managed care entities and the student's primary care physician.
5) The Center's health records must contain
sufficient information to justify the diagnosis and treatment and to accurately
document all health assessments and services provided to the student,
including:
A) a signed consent for treatment
identifying services that may be provided in the Center;
B) the student's name and ID number on each
page in the record;
C)
personal/biographical data including address, home telephone, work phone for
parent(s), type of insurance, managed care entity's name/telephone number and
emergency contact;
D) health care
provider identification;
E) dated
entries;
F) legible records (errors
in charting shall have a single line drawn through, with the date and
practitioner's initials written above);
G) significant illnesses and medical
conditions;
H) medication allergies
and adverse reactions prominently noted in the record; if no known allergies or
history, note appropriately;
I)
appropriate notations concerning use of cigarettes, alcohol and illegal
substances, and other high-risk behaviors;
J) written history and physical documents
with appropriate subjective and objective information for presenting
complaints;
K) laboratory and other
studies ordered, as appropriate, with documented results/findings;
L) working diagnoses consistent with
findings;
M) treatment plans
consistent with diagnoses;
N)
encounter forms or notes with specifics regarding referrals, release of
information, follow-up care, calls or visits;
O) student's refusal of recommended
treatment;
P) notation of
unresolved problems from previous office visits addressed in subsequent
visit;
Q) record of after-hours
care (e.g., emergency room utilization);
R) if a consultation is requested, a note
regarding the results of the consultation;
S) consultation, lab and imaging reports
filed and initialed by primary care provider;
T) evidence that potential risk to the
student from diagnostic or therapeutic procedure has been discussed and
student's response;
U) evidence
that preventive screening and education services are offered in accordance with
the Center's or its sponsoring agency(ies);
V) a record of prescriptions obtained from
and/or provided by the Center;
W)
signed release of information forms, as appropriate, that are dated, identify
what is to be released and to whom, and length of time consent covers and/or is
valid;
X) restricted release
information practices (i.e., family planning, STDs, substance abuse, mental
health) conforming to federal governing laws. (See
325 ILCS
10/1, 410 ILCS 210/1, 2, 3, 4 and 5,
410
ILCS 70/5410 ILCS 305/9k, 410 ILCS 325/3,
405 ILCS
5/3-500 -510.)
6) The Center will request information
regarding previous health history at the time of enrollment to be included in
the health record, including:
A) past medical
and psychological history, including serious accidents, operations, illnesses,
prenatal care, births, substance abuse and mental health needs;
B) immunization records.
7) Records shall not be removed from the
Center.