ESSENTIALS OF JOB CORPS HEALTH & WELLNESS CHARTING

(Medical, Oral Health, Mental Health, and TEAP Charting)

PreambleThis document consists of two parts:

  • Principles of Job Corps charting in the student health record (SHR)
  • Specific examples of documentation to be included with suggestions where to place such documents in a two-sided chart

A. PRINCIPLES:

  1. The primary purpose of the SHR is to provide a complete, concise, accurate medical, oral, mental, and TEAP health history of each student. The SHR may be used for patient care, medico-legal support, education, and research (only with prior approval from the NationalOffice).
    NOTE: All information in the SHR is considered part of a legal document.
  1. Health Insurance Portability and Accountability Act (HIPAA) regulations must be followed in all matters, along with appropriate Privacy Act regulations. (See HIPAA web page for additional information.)
  1. The Center Director and health and wellness manager are the ultimate guardians of all Protected Health Information (PHI) and will set forth the appropriate standard operating procedures (SOPs) to control the security of medical charting. All staff must maintain the confidentiality of PHI. All records must be maintained in a locked file cabinet.
  1. PHI is only to be released per written SOP guidelines and consistent with HIPAA guidelines. The center must contact the Regional Office regarding any records that are subpoenaed.
  1. All health and wellness staff may enter data into the SHR in the appropriate place and are encouraged to continually update the SHR for accuracy and current information as to a student’s health status.
  1. Throughout the student’s Job Corps career, each contact with the health and wellness staff, whether on or off center, must be recorded in the SHR. Staff must record notes of follow-up care planned or given.
  1. Each document placed in the chart must identify that student by two means, e.g. name and birth date or student ID number, etc.
  1. It is preferable that the student’s photograph be included in the SHR (for identification security).
  1. All entries in the chart MUST be legible and recorded/type. Each entry must be dated, including hour of the day and legibly signed or initialed by the data enterer (include title and degree).
    NOTE: If initials are to be used, a master list matching initials of staff with full names is needed.
  1. Findings and treatment rendered must be recorded in the appropriate section(s). Thus, each discipline may have it’s own discipline section, but a notation that chronicles complete care must be entered on the SF-600, Chronological Record of Medical Care, directing the reader to that subsection for details, e.g. DATE and “SEE Mental Health”. There may also be sections for other documentation (lab, x-ray, immunizations, hospital/emergency room care, consultations, etc.). Centers will use dividers in the SHR to separate each section.
  1. When the student is sent off center for care, either the whole chart or a portion can be sent with the student. The off-center care provider must provide at least a summary of the visit to be placed in the appropriate section. Also, documentation of the off-center visit must be made on the SF-600.
  1. When the student exits Job Corps upon completion, separation, MSWR, or death, an appropriate exit note should close out the SHR, stating any referrals or continuing treatment plans given.
    NOTE: See PRH-6 for directions in handling charts for transfer to another Job Corps center or upon death.
  1. Forms shall be filed from top to bottom in reverse chronological order, that is, with the latest on top.
  1. SHRs for residential and non-residential students will be maintained the same manner.
  1. All health and wellness disciplines will maintain their notes in a single SHR.
    Note: Students with disabilities who are receiving accommodations should have a separate file maintained by the disability coordinator that contains all accommodation-related documents.
  1. ENTRIES on the SF-600 must be concise but complete, that is, medically and legally adequate.
  1. Entries on the SF-600 section will:
  • Describe the nature and history of the patient’s chief complaint or condition
  • Record positive or pertinent findings on examination to include appropriate vital signs or test results
  • Record diagnoses and impressions (if made)
  • Record treatment, disposition, and any instructions given the student for later or follow-up care
  • Record all prescribed drugs, side effects discussed, and refill(s) authorized
  • Record all requests for consultation(s), referrals, or other services prescribed
  • Record special procedures or therapies on the SF 600 and final summaries once completed
  • Record preventive health care discussed (e.g., smoking cessation, STIs, contraception for male and female students, etc.)
  • Record if a patient declines care or leaves without being seen
  • Record if the visit is related to an on-the-job injury and ensure that appropriate OWCP forms are initiated (e.g., CA-1)

The above entries are to be done in the SOAP (Subjective, Objective, Assessment, and Plans) format

  1. The SF-600 should contain an entry note documenting the cursory exam detailing any health problems. The record must also contain a reference to the entry physical examination and documentation of any on-going chronic problems and medications authorized by the caregiver to be continued on center.
  1. All charts should have a MASTER PROBLEM LIST/ CHRONIC MEDICATION form that also documents any allergies and any accommodations being given.
    NOTE: Chronic implies of a month’s duration or more.
  1. PREVENTIVE SUMMARY and CHRONIC CARE FLOW forms are desirable as indicated.
  1. Some consistent method of “taking off caregiver orders” (detailed in an SOP) for implementation should be consistently used.

B. DOCUMENTS TO BE INCLUDED:

NOTE : Below is a hypothetical arrangement of a Job Corps SHR (and is what many centers currently do). Each center may design it’s own format – but that format must be consistently used for all SHRs.

DOCUMENTS for PART I

(LEFT SIDE OF SHR from top to bottom):

  1. Master Problem List/Chronic Medication Form/Allergies/Accommodations
  2. Preventive and/or Chronic Care Flow Sheets
  3. Student’s Personal Health and Wellness Goals
  4. SF-93, SF-88, and SF-603 Forms
  5. Growth and/or BMI Plotting Forms
  6. Oral Health Progress Notes
  7. Emergency Contact Information
  8. Copy of the Disability/Accommodation Plans if Medically Related
  9. Consent Forms (e.g., HIPAA, HIV, Immunizations, and Informed Consent for Mental Health and Wellness Services)
  10. Insurance Information
  11. Other (e.g., Optometry Prescription, Hearing Screen)
  12. Request and Release of Medical Information Forms/Documentation
  13. SHR Audits

DOCUMENTS FOR PART II

(RIGHT SIDE OF SHR from top to bottom)

  1. SF-600 Notes in SOAP Format/Caregiver Orders
  2. Discipline Specific Progress Notes (Mental Health, TEAP, and Oral Health - if not elsewhere)
  3. Immunization Records
  4. Laboratory/ X-ray Reports/ Drug Testing Results
  5. Off-center Consultation Notes/Emergency Room Notes (though summarized on the SF-600)
  6. Hospitalization Summaries
  7. Previous SHRs from Before Entry into Job Corps
  8. CA-1 or CA-2 Forms and Copies of all OWCP Forms if Applicable
  9. Other

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