Oklahoma Department of Corrections

OKLAHOMA DEPARTMENT OF CORRECTIONS

MEDICAL SERVICES DIVISION

DATA DEFINITIONS

DRAFT– Monthly Medical Activity Report (OP-140107) - DRAFT

Instructions: Please complete the following for the previous calendar month. By the 5th of the current month, enter the data in the Medical Activity Report System and keep a copy for your files. If you have any questions, please call the Medical Services Division.

Month/Year: ______Facility: ______

SECTION ONE: MEDICAL ENCOUNTERS & SERVICES COORDINATED
AT FACILITY

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Primary Care (NOTE: include all visits to physicians, nurses, PA, NP, etc.) (OP-140117)
Number of sick call encounters (1A-24) / Total sick call slips for medical, mental health, and dental.
Scheduled medical appointments (1A-25) / Number of visits performed by physician, PA, Nurse Practitioner, or Nursing staff.. Include pre-triage, wound care, nursing protocols, dressing changes. Exclude physical exams, labs, x-ray, and items reported elsewhere
Physician
Physician’s Assistant
Nurse Practitioner
Nursing Staff
Emergencies seen in the clinic / Unscheduled visits of an emergent nature. An unexpected health care need that cannot be deferred until the next scheduled sick call or clinic. Includes all potentially life-threatening circumstances and all contacts associated with significant potential for loss of limb or major bodily function.
Total number of encounters in pill pass, KOP, etc. (1A-36) / Pill line activity. Also include SHU pill encounters, insulin injections, oral and IM medications. We are counting each time an inmate is seen.
After Hour Callbacks (OP-140101)
Physician / Number of times staff returned to facility during month. For Mental Health staff, refer to the page completed by them to get number for callbacks.
Physician’s Assistant
Nurse Practitioner
Nursing staff
Dentist
Mental Health staff
Health Services Administrator
Other
SHU Medical Visits (OP-140117)
Nursing staff / The number of visits to the SHU for medical activities. Only include nursing staff. Just put total for “Other” – no need to itemize. See Mental health visits from the Mental Health page to include here.
Other
Medical Activity Restrictions (OP-140107)
Temporary inmate lay-ins / Short term with an estimated discharge date. “…medical, dental or mental illness or injury with an order from a qualified health authority that restricts return to regular activities as documented in hours, days, weeks, or months.”
Medically unassigned / Long term. “… medical dental or mental health illness or injury with an order from a qualified health authority that has no potential of return to regular activities.”
Medical Special NeedsA medical condition that requires the need of assistant devices or inmate has a medical impairment (OP-140133).
Number of inmates in wheelchair
Number of inmates who are vision impaired / Legally blind, cataracts, glass eye. Do not include inmates with just eyeglasses.
Number of inmates who are hearing impaired / Hearing aids
Number of inmates using walkers, canes, crutches
Number of inmates using prosthesis / “A functional or cosmetic, artificial device that substitutes for a missing body part such as an arm, leg, eye, or tooth.”
Therapeutic diets (OP-070202) “A diet prescribed by a health care practitioner as part of the patient’s medical treatment.”
Diet for Health (1A-30; 1A-31; 1A-32) / Diabetic diet, heart
Mechanical Soft (1A-30; 1A-31; 1A-32) / Dental diet
Renal Diets (1A-33)
Other / Liquid, allergy.

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Testing and ScreeningNumber of tests performed in your facility and how many tests performed in outside facilities. Utilization of facilities due to not having the capability to perform the screenings in your facility. For example, x-rays.
Test (limit to inmates) / On-site Completed at your facility / Off-site Contracted. Activity not completed at facility / Test (limit to inmates) / On-site Completed at your facility / Off-site Contracted. Activity not completed at facility
PPD (1A-3) / Tuberculin skin test / Number of CXRs sent to OSDH / How many chest x-rays were sent to the Oklahoma State Department of Health?
Positive PPD reading (1A-1) / Include 10 x 10 results for regular population AND 5 x 5 results for high risk population / X-ray Total / Include all x-rays of extremities, chest, etc. but NOT dental.
Serious Injuries and DeathsA process of reporting critical occurrences (OP 140111, OP 140125, and OP 14029)
Assaults - inmate to inmate (6A-7) / Inmates only / Accidental (inmates) (6A-3) / Inmates only
Assaults - inmate to staff (6A-7) / Staff only / Work-related (inmates) (6A-3) / Inmates only
Sexual assaults - inmates and staff / Include staff. Inmate to inmate and inmate to staff. / Sports (inmates) (6A-3) / Inmates only
Self-mutilations (inmate) / Inmates only / Bloodborne pathogen exposures: staff / Staff only
Attempted suicides (inmates) (1A-9) / Inmates only / Bloodborne pathogen exposures: inmates / Inmates only
Deaths (include suicides and executions) / Inmates only – includes suicides and executions / Medication administration errors (1A-36) / Inmates only
Needle-stick injuries (staff) (1A-34) / Staff only / Pharmacy dispensing errors (1A-35) / Inmates only
Total medical grievances (inmates) / Inmates only
Specific Illness CountsThis section will capture data on incidence and prevalence for comparisons (OP-140137, OP-140125, OP 140301; MSRM 140137-03, MSRM 140137-06)
Illness (Note: a patient with multiple diseases must be counted for each category listed below) / Prevalence: Total number of known patients at facility (includes newly diagnosed) / Incidence: Number of newly diagnosed patients at facility within this month
Chronic/Serious Illness: “…a disease process or illness that persists over an extended period of time” An illness that is either ongoing or recurring over a course of several months to years.
Asthma
Pulmonary / Includes COPD
Diabetes (1A-27)
Endocrine
Hypertension (1A-27)
Cardiovascular
Seizures
Cancer
Infectious/Communicable Disease “ a disease that can be transmitted between person to person”
Tuberculosis Disease
TB Infection: currently on treatment (1A-2; 1A-3)
AIDS/HIV (1A-6, 1A-7)
AIDS/HIV : currently on treatment (1A-7) / How many inmates with AIDS/HIV are on treatment at your facility?
Hepatitis A
Hepatitis B
Hepatitis C (1A-5)
STD (sexually transmitted diseases)
Other infectious/communicable disease (please list and total on this line) (5A-1)
Hygiene related conditions (scabies, lice, fungal infections, etc.) (5a-1) / “Parasites that live on the outside of the host . Examples: fleas and lice.”
Other
Specialty Care Visits (report only clinics that have been completed) (1A-18)
Specialty Care Not Completed (use additional sheets if necessary)
SECTION TWO: COMMUNITY AND EMERGENCY CARE

Services provided outside your facility to inmates

Hospital Admissions and Emergency Care
Off-site emergency room visits Care for an inmate with an acute illness or unexpected health care need that cannot be treated at your facility (OP-140118)
OU MedicalCenter
Local hospital
Hospital admissions from emergency room visits (1A-16) / How many hospital admissions followed an emergency room visit? This includes admissions to LindsayHospital, OUMC, and local hospitals.
Hospital admissions from non-ER visits (1A-16) / How many regular hospital admissions? This includes admissions to LindsayHospital, OUMC, and local hospitals.
Total number of hospital days during month
Number of inmates in hospital during month
Inmates in Medical Care Elsewhere
Inmates in nursing home
Inmates in palliative care
Facility Transfers to an Infirmary (other than your own) (OP 140119)
OSP / This part is only to be filled when a facility transports inmate patients to an infirmary. It captures the number of inmates that your facility moved to one of the following facilities with an infirmary: OSP, MBCC, LARC, DCCC, GPCF.
MBCC
LARC
DCCC
GPCF
Other (Total on this line and list below)
SECTION THREE: SPECIALIZED TREATMENT UNITS AND CARE
Tab 3
Infirmary Report (NOTE: this section is only to be completed by the following facilities: OSP, MBCC, LARC, DCCC, GPCF) Area within the confinement facility, accommodating two or more inmates for a period of 24 hours or more, expressly set up and operated for the purpose of caring for patients who are not in need of hospitalization or licensed nursing facility placement, but whose care cannot be managed safely in an outpatient setting (OP-140119).
Total infirmary admissions this month (1A-15) / Total infirmary discharges this month
Tab 3
Women’s Health Care Report (NOTE: this section is only to be completed by the following: MBCC, EWCC, LARC, KBCCC, TCC) (OP 140145)
Pap smears / Number of births – c-section (MSRM 140145-01)
Mammograms / Number of births – vaginal (MSRM 140145-01)
Number pregnant (new and current)
Tab 4
Mental Health Unit Report (NOTE: this section is only to be completed by the following facilities: JHCC MHU, MBCC MHU, and OSP MHU) (OP-140127)
MHU referrals - referred and placed on observation/evaluation status / MHU referrals – referred and not admitted to observation/evaluation status
Number of inmates newly admitted to MHU / Number of inmates discharged from MHU
Tab 4
Private Facilities’ Medication Encounters to include prescriptions obtained from both DOC pharmacy and private venders (NOTE: this section is only to be completed by private facilities. Data for DOC facilities is collected from DOC pharmacy system) (OP-140130)
Number of prescriptions (1A-35) / Number of psychotropic medications
Number of inmates on medication / Number of inmates on psychotropic medications
SECTION FOUR: MENTAL HEALTH SERVICES MONTHLY ACTIVITIES
Treatment or Contact / Psychiatrists / QMHP (qualified mental health professional)
Number of individual inmates seen in individual therapy/counseling / This is the number of inmates who have attended at least one individual session with you. You are counting individual inmates here so there should not be any duplication.
Total number of individual therapy/counseling sessions / For this item, you are counting the number of individual sessions that you provided. This should be at least be equal to the number of inmates seen. It can be more if some inmates received more than one session.
Number of individual inmate contacts in group therapy/counseling or psycho-educational groups / How many inmates attended a group session this month? Remember that an inmate will only be counted once for this item.
Total number of group sessions / How many group sessions did you provide this month?
Number of inmates administered a psychological battery (evaluation) / This is the number of inmates who took some type of psychological test. Do not overcount here. If an inmate completed a WAIS one day and an MMPI another, you only have one inmate to count.
Number of inmates seen for crisis intervention / Some inmates may seem to have a predisposition for a crisis every week but you only count the inmate and not each episode.
Number of contacts seen for crisis intervention
Number of MHU therapeutic contacts (MHU facilities only) / How many times over the month did you have contact with inmates in MHU? This may end up looking like an inflated number but you are counting the number of contacts. It is possible that several inmates are contacted every day.
Number of inmates seen for clinical interview and/or mental status exams (other than SHU and LARC) / Again, you are counting inmates and not the number of exams or interviews.
Number of inmate contacts during SHU semi-weekly reviews / Every other week, you may have an individual inmate contact at RHU (SHU). For this item, how many times did you have contact with an inmate on RHU (SHU)?
Number of inmates seen for 30 or 90 day SHU mental status exams / Again, you are counting the number of inmates and not exams.
Number of inmates participating in group psychological testing at assessment center / Although this is testing at a group level, you want to ask yourself: How many inmates went through group testing?
Number of inmates seen at assessment center for clinical interviews / Count the number of inmates and not interviews.
Number of incidents involving restraints / How many times was there an incident involving restraints?
Number of enforced medication incidents / How many times did you participate in an enforced medication incident?
Number of inmates on non-emergency involuntary medication. / For this item, count the number of inmates on non-emergency involuntary medication.
Number of inmates on psychotropic medications / How many inmates you see are on psychotropic medications?
Number of inmates seen for psychotropic medication management / How many inmates did you provide psychotropic medication management?
Number of contacts for psychotropic medication management / For this item, count the individual contacts with the inmate. For example, the previous item could be 2 inmates seen for medication management BUT there were 4 contacts since one inmate was seen 3 times.
Total number of hours MH staff delivered in-service training (includes both medical and non-medical staff) / How many hours did you spend providing in-service training?
Number of staff consultations / How many consultations did you provide to staff (all staff) this month?
Number of after hour callbacks / Count the number of time within the month that mental health staff returned for a call
SECTION FIVE: DENTAL SERVICES MONTHLY ACTIVITIES
Tab 4
Clinic Visits & Requests For Care / Dentist / Hygienist
Routine visits / Appointed patients
Unscheduled visits/Emergency visits / Visits by patients with urgent needs, not appointed in advance
Total visits failed/canceled by clinic or patient / Include no-shows, lockdowns, schedule change, etc.
Total clinic visits / Routine visits + Unscheduled visits – visits failed/canceled
Total sick call requests / Number of Requests for Medical Services received
Tab 4
Services/Procedures Provided / Dentist / Hygienist
Total complete exams with treatment plans (1A-26) / “An examination by a licensed dentist that includes a dental history, exploration and charting of teeth, examination of the oral cavity and x-rays.”
Total preventive procedures / Prophys, oral hygiene education, plaque indices
Total treatment procedures
Periodontics / Gross scale, scale/root plane, probing
Restorative / Fillings (temp. or permanent), crowns,
Endodontics / Completed root canal treatments, pulpectomies, pulpotomies
Oral surgery (on site) / Alveoloplasty, extractions, biopsies, etc.
Prosthodontics / Appointments for impressions, adjustments, wax try-ins, delivery, etc.
Prophylaxis / Cleaning & polishing to include minor scaling
Gross scale/curettage / Removal of large deposits of calculus (subgingival primarily) to prepare patient for further treatment
Deep scale/root plane / Scaling and root planing, reported by quadrant, to remove subgingival calculus deposits

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