Commissioner's Directive
| Number - Numéro: 835 |
Date: 1995-05-01 |
Health Care Records
Issued under the authority of the Commissioner of the Correctional Service of Canada |
1. To facilitate the provision of effective medical and health services to inmates by keeping consistent health care records.
2. Inmates have the same rights to confidentiality of information obtained by a health professional as exist in the general community. The management of health care records shall conform wherever practical to norms established by the general health care community. The management of such records shall be the responsibility of health services staff.
3. Health care records shall not be part of the confinement record of an inmate.
4. There are two basic components of the health care record: the institutional health care record and the Regional Psychiatric Centre record. These records shall be managed as separate entities and held together only when the inmate is at a Regional Psychiatric Centre or when they are being stored at Public Archives.
5. An institutional health care record shall be created when an inmate is admitted to the Service. If an inmate has served a previous sentence in a federal institution, a temporary file shall be created and used until the existing record is retrieved.
6. A Regional Psychiatric or Regional Treatment Centre file shall be created only upon admission to such facilities.
7. The institutional health care record shall move with the inmate throughout the sentence, while the Regional Psychiatric or Regional Treatment record remains at the respective centre until final disposition.
8. Every significant interaction between an inmate and any member of the health services team shall be noted on the offender's health care record, including a summary of the nature of the interaction, the time of the interaction and a description of the action taken by health services staff.
INCLUSION OF HEALTH CARE INFORMATION ON INMATE RECORD
9. A health care administrative summary outlining significant findings to those involved in the supervision of an inmate shall be provided for placement on the inmate record.
10. Health care records shall be retained until ten years after the most recent warrant expiry date or according to the provincial legislation where the inmate was last treated medically, whichever is the longer period of time.
11. Regional policy shall be developed for the management of active health care records for those inmates housed in facilities which lack on-site health services staff and for dormant institutional records.
Original signed by
John Edwards,
Commissioner