All inmate medical records shall be maintained and controlled by Correctional Health Services (CHS), in accordance with the Minimum Standards for Local Detention Facilities, section 1205, "Medical/Mental Health Records." These records shall include, but are not limited to:
• Receiving screening form
• Medical/mental health evaluation reports
• Complaints of illness or injury
• Names of personnel who treat, prescribe, and/or administer/deliver prescription medication
• Location where treated
• Medication records in conformance with the Minimum Standards for Local Detention Facilities, section 1216, "Medical/Mental Health Care Procedures Manual"
In the case of an inmate death or injury, Department investigators may obtain information from the inmate medical record, or the record (or portions thereof) itself, in order to protect the health and safety of the inmates, and to ensure the safety and security of jail operations. Only authorized requests made pursuant to this policy will be granted. Except as otherwise provided by law, for any other use of an inmate medical record, either a release, warrant, or court order must be obtained.
All requests made pursuant to this policy shall be made via the “Request for Confidential Medical Information/Records” form (with the limited exceptions specified below), and shall be limited to the minimal amount of information necessary for the investigatory purpose.
In the case of an inmate death, a certified copy of the entire medical record of the deceased inmate will be made available to Homicide investigators upon their request. The Homicide detective may request the record by presenting his/her business card, along with the name and booking number of the inmate, to Health Information Management Department, Release of Information Unit (via fax number [REDACTED TEXT] or in person at Room 6024 of Men’s Central Jail). The record will be provided to the Homicide investigator immediately if possible, but in any event within 24 hours.
Custody Support Services personnel may request the deceased inmate’s medical record, portions thereof, or information therefrom for the purpose of conducting and documenting a thorough death review. Such requests will be made via the “Request for Confidential Medical Information/Records” form and shall be limited to the minimal information necessary.
In the event an inmate suffers a disabling injury such that he or she is unable to execute a release as to his/her medical records, investigators may obtain information and documentation directly related to the subject injury from the injured inmate’s medical record.
Department personnel conducting administrative and/or other internal investigations related to the death or injury of an inmate may obtain information from the deceased/injured inmate’s medical record to the extent necessary to conduct a thorough investigation. Any information and/or documents obtained from the inmate’s medical record shall be maintained in a separate file marked “Confidential”and shall be considered and treated as privileged and confidential. Unless otherwise required by law, the information/documents obtained shall not be disseminated further without a signed release or court order, and in such cases a protective order shall be sought.
When conditions exist which constitute an immediate threat to the health or safety of any person(s) in the jail system, limited information necessary to the resolution of the threat shall be immediately provided in the most expedient manner possible (i.e., by telephone, radio, etc.).
In the event of a dispute as to the adequacy of the information provided on the “Request for Confidential Medical Information/Records” form, the necessity for the information or the records, or the adequacy of the information or records provided, each unit shall submit the dispute to the director of CHS and the concerned unit’s Unit Commander. The two Unit Commanders (or their designees), if necessary in consultation with County Counsel, shall reach an agreement to resolve the dispute.