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Southern Health Partners, Risk Management Guide for Services

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Southern Hea]th

Partners
Your Partn er In Afford ab le Inmate Healt hca re

RISK
MANAGEMENT
GUIDE OF
SERVICES

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Table of Contents:
Contact Information
Risk Management
What is Risk Management?
Tips for Minimizing Risk within your Job Duties
Chart Smart Documentation
What to report to the SHP Risk Management Department
What is Deliberate Indifference?
What is Professional Negligence?
Monitoring
Ethical Obligation
Incident Reports
Report of Inmate Death
Requests for Medical Records
Social Security, State Disability Determination, or other Governmental Agencies
Lawyers, Inmates Friends, Family, or 3rd party requests
Inmate requests for records
Medical providers requesting records
Legal Process/Lawsuits/Claims
Lawsuits
Subpoenas & Court Orders
Remember Where you Work
Health Information Patient Portability Act (HIPAA)
Family member Calls
Sharing Information – Provider to Provider
Calls from the Media
Legal Questions
Forms -

Incident Report Form
Report of Inmate Death
Authorization for Release of Patient Medical Record

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CONTACT INFORMATION
Corporate Office:
Main Phone: 423-553-5635; Main Fax: 423-553-5645
Brooke Shirley, Risk Management Assistant, ext. 935, brooke.shirley@southernhealthpartners.com
Janet Stephens, VP Quality Assurance, ext. 939, janet.stephens@southernhealthpartners.com

RISK MANAGEMENT
The Risk Management Department handles incident reports, inpatient reports and legal matters.
Risk Management is here to answer legal questions SHP staff may have, and provide training
on legal compliance and risk reduction. We have an Open Door Policy. If you have a question,
please ask.
What is Risk Management?
The process of Risk Management is designed to reduce and/or eliminate the risks that may
have an impact on our business. Risk Management is a process for identifying, assessing, and
prioritizing risks of various degrees. Once the risks are identified, the Risk Management
Department will create plans to minimize or eliminate the impact of negative events.
Tips for Minimizing Risk within your Job Duties:
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Performing Quality Patient Care
Good Documentation Skills
Follow through with Treatment Care Plans
Good Documentation Skills
Review of Previous incidents
Good Documentation Skills

Hopefully you are seeing a pattern here – Good Documentation Skills are key. The following
information will help you to “chart smart”:
Chart Smart Documentation
As healthcare delivery becomes more complex, and patient care needs increase, accurate
documentation is essential. The main purpose of documentation in the medical record is to
document relevant data and to communicate to others, especially the healthcare team, the
patient’s care and progress. Failure to document data may be considered itself a breach of and
deviation from the “standard of care”.
This includes a diagnosis made by the
physician/physician provider, assessment, treatment plan, implementation of the treatment plan
and evaluation by nurse staff. It is very important for nursing staff to pull a patient’s medical
record prior to seeing that patient, so they can review previous notes and information regarding
the patient’s care and treatment plan. Further, it is essential for each nurse/medical staff
member to keep filing current, so all information is available in the medical record.

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Often, in a chaotic environment, documentation can become difficult and insufficient. Improper
documentation can have disastrous consequences. Errors and omissions in documentation can
be a significant liability for nurses as well as the Company. The medical record is the most
single important document available to nurses facing negligence actions. Without a complete
and legible medical record, nurses may be unable to defend themselves successfully against
allegations of improper care.
Correctional nurses have a high degree of accountability and responsibility. They are also
highly subject to possible litigation brought by the inmate patients. The growth in nursing
leadership positions has contributed greatly to improvements in delivery of services and quality
of care in correctional environments.
Remember, documentation is only as good as the information it contains. Documentation
establishes a list of problems and provides evidence that the standard of care was met.
Impeccable documentation is worth its weight in gold! Good documentation also helps provide
legal protection if correctly documented events and information is contained within the medical
record.
Tips on Good Documentation – REMEMBER the “W’s”: WHO, WHAT, WHEN, WHERE and
HOW:
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Record only facts, not opinions or judgments – we often see nurses documenting
comments made by officers, i.e. “inmate vomiting blood”, only to find out in
deposition the comment was what the inmate told the officer – no one ever saw
the inmate vomiting blood, nor was there evidence of such in the cell, the toilet,
etc. By the nurse documenting that statement, and then not showing any
intervention except vital signs taken, could pose as a deliberate indifference by
the nurse. So again, record only facts - “officer states inmate told him he was
vomiting blood, no evidence of such noted in cell, will monitor patient….”
Record date and time of any events or entries
Document any inconsistencies or delay in treatment – we need to chart any
issues which prohibit the nurses from completing their work. For example, you
go to check on a diabetic inmate in intake, but the officers are unable to allow
you in the cell due to dealing with another inmate’s altercation with an officer.
You must chart such otherwise it seems from a review of the medical record the
nurse may have delayed her treatment of the patient. Without the benefit of the
nurse’s note as to why there was delay (especially if the patient develops
problems later) the reader of the record would surmise the nurse was lacking.
Document the physical assessment of the patient;
Document any teaching or instructions given, and if patient understanding was
indicated – if you are placing the inmate on new medicine, or have wound care
instructions, etc., a simple note of you advising the patient to contact medical
staff if there are any problems or changes will be considered excellent
documentation.
Always sign/date all nursing notes.
Document conversations with any family members, friends, etc. – Be careful to
not release any patient protected confidential medical information (HIPAA). You

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
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can listen to someone’s concerns, and follow up with the patient based on the
information you received, but you cannot release information to the friends/family
members.
Always include a fresh set of vital signs when you are monitoring the patient –
Temp; BP; Pulse; and Resp.
Use permanent ink for entries, and do not use white out anywhere in the patient’s
medical record. If you make a mistake, draw a line through the entry, sign/date
that correction.
Do not leave blank spots on forms – answer all questions, and if the question is
not applicable, write in N/A. Or draw a line through the blank.
Always record a patient’s non-cooperative or non-complaint behavior.
Record only your own observations and actions. If you receive information from
another person, state the source of the information – i.e. “patient states….”
“officer states….”
Write legibly. The medical record becomes evidence that is reviewed by
Attorneys, Judges, other medical providers, and juries. A legible record reflects
the level of care provided.

Here are some BAD examples/Red Flags in Nursing Documentation:
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Lack of Treatment
Delayed, substandard, or inappropriate treatment
Lack of patient education
Late entries that aren’t documented as such, or appear to be self-serving rather than
genuine.
Fraudulent or improper alterations of the record
Missing records

Correctional nursing is a professional specialty area that is becoming recognized around the
world. It offers the opportunity to practice nursing in a unique atmosphere with other multidiscipline health care providers. Correctional nursing offers autonomy and the opportunity to
participate as a leader in the treatment team concept.
While correctional nurses may deal with the same issues as the public sector, we have the
added responsibility and challenge of providing quality nursing care to an unpopular population.
Remember, the medical record is a legal document and it is the most credible evidence in legal
proceedings.

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What to report to the SHP Risk Management Department:
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All Inmate/Patient Deaths. If after normal business working hours, feel free to
call and leave a voicemail mail message for either Brooke Shirley (423/553-5635
x935 or Janet Stephens (423/553-5635 x939). Provide the basics of information:
Patient’s Name; Age; Intake Date into Jail; Time of Death; Brief Description of
what happened (heart attack, etc.). Follow-up will take place the next business
day for more information.

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Lawsuits. If you receive a copy from the Jail Administrator, or are served at the
site (sometimes delivered in the mail), please fax it to Brooke Shirley, Risk
Management Assistant at the SHP corporate office (423/553-5645 x939).

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Delays in Treatment which caused Grievous Injury. You can send us an Incident
Report Form detailing the information. As an example, you wanted to send an
inmate to the ER but there was a delay due to EMS being unable to be at the site
timely, and the inmate suffered harm as a result, we want to know about this.

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Serious Detoxification / Withdrawal Issues. Please submit an Incident Report
Form detailing the incident. As an example, report issues where the patient
wasn’t identified as a potential detox patient on intake, or the patient wasn’t
screened timely, and then went into severe withdrawal, resulting in
hospitalization or further harm.

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Amputations / Loss of the use of limbs / paralysis.

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Medication Errors. Please submit an Incident Report Form detailing the error.

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Investigations / Records Request. Please review the information later in this
manual as to Records Request.

What is Deliberate Indifference?
Deliberate indifference is the conscious or reckless disregard of the consequences of
one’s acts or omissions. Deliberate Indifference occurs when a professional knows of
and disregards an excessive risk to an inmate’s health or safety. Even though it is
difficult to identify what does and does not constitute deliberate indifference, courts have
recognized several factual scenarios where deliberate indifference exist.
Example: Patient at intake states he/she is a diabetic, and takes insulin several times a
day, and gives his/her pharmacy and Provider information. The nurse evaluates the
information, sees the patient, and then doesn’t order insulin for the patient. The patient
is sent to the ER with Diabetic Ketoacidosis. This could be Deliberate Indifference.
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What is Professional Negligence?:
Professional negligence is the failure (breach of the duty of care) to provide the
standard of care to a patient, resulting in an injury or damage to patient. Duty is
established when we accept care of the patient, requires you to provide the standard of
care that a reasonably prudent nurse would provide for a similar patient under similar
circumstance.
Example: Patient has a “spider bite”, is assessed by nurse who gives patient a bandaid. Patient is later diagnosed with MRSA and has to have an I&D. This could be
professional negligence – wouldn’t a reasonably prudent nurse have monitored the
patient on Wound Care? Contacted the Physician for order of antibiotics?
Monitoring
If you feel the patient’s condition warrants monitoring, then MONITOR! Document your
monitoring – SHP has many forms in which to use, for all types of monitoring, and of
course, you can always document your findings in progress notes as well.
Make sure other nurses, medical staff, and officers are aware of the patient being
monitored, as they can be your eyes/ears when you aren’t around. Of course you
should alert the patient to also notify you if his/her situation changes, or they need
further medical assistance.
Ethical Obligation
If at any time a SHP staff member feels violations of policy and procedure or
inappropriate behavior has occurred, they have a duty to report such to our SHP
representatives (H.R., Risk Management, VP of Operations, Region Representatives).
We want to hear from you! This isn’t about being a “tattle-tale.” This is a way for SHP
to provide a safe and ethical work environment for our staff and our patients.
SHP feels it is our obligation to investigate each report fairly and fully. We ask
employees to provide information to the best of their ability and otherwise assist in the
investigation if called upon to do so. Anonymous reports can also be made by email or
voicemail, or fax, but please know it may be harder for us to investigate without the
benefit of talking to someone.

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INCIDENT REPORTS
What is an “incident”? SHP describes an incident as an individual occurrence or event, an
unplanned disruption or degradation of services or an episode. An “incident” can lead to serious
consequences to patient care, and ultimately a lawsuit.
Incident Report - An incident report is the form filled out in order to record the details of an
unusual event that occurs at the facility, such as an injury to a patient. The purpose of the
incident report is to document the exact details of the occurrence while they are fresh in the
minds of those who witnessed the event. This information may be useful when dealing with
liability issues stemming from the “incident”.
SHP medical staff promotes patient safety through review of processes and symptoms regarding
adverse and/or possible near-miss clinical events. In an effort to reduce risk and/or harm to
patients, SHP encourages medical staff members to identify potential problems to the MTA
and/or corporate Risk Manager through our incident reporting system. All medical staff members
should be trained as to incident reporting upon their orientation. An open forum is encouraged to
properly identify problems, risks and the potential for risks within the jail medical unit.
SHP considers the following as reportable “incidents” to the corporate Risk Management
Department:
 All Inmate Patient Deaths
 Acute neurological deficits/injuries
 Delays in treatment and/or diagnosis which cause patient harm
 Repeat visits to the ER for the same complaint
 Suicide attempts
 Miscarriages/ reproductive organ loss/impairment
 Infections/Sepsis/Suspected MRSA/Staph
 Detoxification Issues which caused patient harm – days in treatment, from bad to worse,
had to be sent to ER for further treatment, etc.
 Amputations/Loss of use of limb(s)
 Spinal cord injuries – causing temporary or partial paralysis
 Disfigurement/burns (2nd/3rd degree)
 All Attorney Contacts who represent inmate plaintiffs
 Threatened litigation
 Forced medication and/or psychiatric intervention
 Medication errors
 Press/Newspaper inquires/Investigations
 Needle sticks NOTE: All employee injuries are to be reported to the SHP HR department.
An incident report form, is a confidential report (using the SHP Incident Report Form) submitted
by you from the site to our corporate office Risk Management Department. When completing an
Incident Report Form, keep in mind that we, at the corporate office, probably haven’t heard
about the incident before. We will be curious, so consider the types of questions we may ask
and include those answers as information in your report. Every incident report should have a
beginning, a middle, and an ending. Always read back over what you have written, because if
you can’t understand it, I promise we can’t either! And remember, each section of the incident

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report form must be completed, and if you need more space, use the back of the form, or attach
another piece of paper. NOTE: Please put both your site number and site name on the form.
Incident Report forms should be signed by the person filling them out as well as by the MTA.
Once you have completed the SHP Incident Report Form, fax it to SHP corporate (Brooke
Shirley’s attention) at 423-553-5645. Incident Reports should be sent to Risk Management by
fax or mail within 24 hours of the incident. Major incidents should be reported to Risk
Management by telephone so that we are aware of them, thought you must still complete an
Incident Report as well. Staff are expected to use their own judgment as to what incidents merit
a telephone report, but you should always feel free to call. If you fax your reports the original
must be mailed to Risk Management, but you may hold the original for mailing until the end of
the week. If you do not fax your reports, you must mail them as soon as possible. Again, mail
the original form with your other mailing to the corporate office (so we save some postage!), as
we do NOT want you to keep a copy at the site level, or in the patient’s medical record.
Risk Management at the corporate office receives, logs, and tracks all Incident Reports which
arrive from the site.
Incident reports are not medical records, they are internal SHP documents. Do not file
incident reports in the inmate’s medical file or provide a copy to any non-SHP person.

REPORT OF INMATE DEATH
Deaths will happen in a correctional facility, much like they happen in a home, on the street, and
in the hospital. We cannot predict when, or even how, but we can manage the event under Risk
Management policies and procedures.
All inmate patient deaths must be reported immediately to the MTA, Medical Director, Jail
Administrator, corporate office and regional representative. Information reported is considered
confidential, and may be used in litigation.
In the event of an inmate’s death on-site at the jail facility, the nurse must immediately notify the
MTA, Medical Director, Jail Administrator, and corporate office.
For after business hour
notification, the SHP corporate office has a voicemail where a message can be left as to the
event. Call either Brooke Shirley (423/553/5635 x935) or Janet Stephens (423/553/5635 x939).
In the event of suicide, homicide, accidental or suspicious death, the Medical Examiner and
appropriate law enforcement officials will be notified by the Jail Administrator or designated
correctional officer. The MTA and Medical Director will be advised of such findings where
necessary.
The designated security staff will notify the inmate’s next of kin. The medical staff is not to have
any discussions regarding the incident with family members, media, or other outside parties. All
such requests must be forwarded to the Risk Management department at the corporate office for
handling and response.

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A progress note MUST be made by the nurse on duty citing witnessed facts concerning:
Time of expiration, Nature of death;
Circumstances surrounding nature of death at that time;
Treatment rendered, if any;
Persons notified of death;
Whether an autopsy was/was not requested;
Medical staff and/or SHP personnel are not to release any information or records concerning the
death to outside media (newspapers, reporters, etc.). In most cases the state bureau of
investigation will be on-site and seize the original medical record for review. Please alert the
investigator of any additional notations which need to be documented in the record. The nurse on
duty will make a copy of the medical record to send to the corporate office for reporting purposes.
Within 24 hours of the incident, the MTA will complete and forward the Report of Inmate Death
Form to the corporate office, along with a copy of the inmate’s medical record. If the state
investigation team has control of the record before medical can make a copy for the corporate
office, send a copy once the original record is returned.
A SHP corporate representative will conduct an initial interview with staff members involved. This
is standard practice. All reports, along with a copy of the medical record, are forwarded to the
company’s insurance company for work-up and review, which is why it is imperative to get the
information as quickly as possible. The review may include the role of medical staff in the event
of inmate’s death, as well as determine the appropriateness of clinical care given to the patient.
Critical Incident Stress Debriefing:
Remember an inmate suicide can be extremely stressful for staff and they may be feeling
misplaced guilt over the incident (maybe I should have checked a minute before, maybe I could
have done harder chest compressions, etc.).
Critical Incident Stress Debriefing is a process that prevents or limits the development of posttraumatic stress in people exposed to critical incidents. Debriefings help people cope with, and
recover from an incident's after effects. Staff need to understand they are not alone in their
reactions to a distressing event, and this process provides them with an opportunity to discuss
their thoughts and feelings. The review/debriefing should occur within 24 to 72 hours of an
incident.
On-site Critical Incident Review / Morbidity-Mortality Review (MMR):
To ensure good communication between the medical staff and the correctional officers, a review
of the critical incident should be completed within 72 hours of the incident. The MMR meeting
should be attended by both the Jail management and SHP medical team management staff to
perform a critical inquiry into the circumstances of the event, and the subsequent response by
all involved in the incident. The intention of this meeting is to identify any corrective action going
forward, and to recommend any changes in policy, procedures, training or services to possibly
prevent another event such as this from happening in the future.

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The review process shall comprise a critical inquiry of the following:
 The circumstances surrounding the incident.
 The facility procedures relevant to the incident.
 All relevant training received by involved staff.
 Any pertinent medical and mental health reports/services involving the victim.
 Any positive precipitating factors leading to a death, a suicide or serious suicide attempt
and follow-up recommendations, if any, for changes in policy, training, physical plant,
medical or mental health services, and operational procedures. When appropriate, the
Morbidity-Mortality Review Team should develop a written plan and timetable to address
areas that require corrective action.
The Medical Team Administrator will need to send notification to the corporate office Risk
Management Department that such a review process has been completed.
Again, the SHP Corporate Office Risk Management Department is to receive and process all
reports of inmate patient deaths. A Report of Inmate Death is to be completed any time there is
a death of an inmate patient in your facility. Even if Medical was not involved in responding, or if
Medical staff were not in the facility at the time – you still must complete a Report of Inmate
Death and send it in to the corporate office. We report all such incidents to our insurance carrier
for possible litigation.
Fax the Report of Inmate Death to Risk Management at (423) 553-5645. Mail the original to the
corporate office to Risk Management with the complete copy of the inmate’s medical records.
Do NOT place a copy of the Report of Inmate Death in the inmate patient’s medical
record.

REQUESTS FOR MEDICAL RECORDS
In the facilities in which we work, SHP staff are custodians of the inmate’s medical records.
Which means the medical records belong to the jail, not to SHP. The following procedures
below are to be followed for handling medical records requests, but if jail administration asks for
a file, it should be immediately given to them. While we can advise jail administration on when
to give out medical records if they ask, the files belong to them, not us.
In most of our contracted facilities, jail administration expects SHP staff to handle medical
records requests. As healthcare providers, SHP and our staff have specific obligations under
state and federal law to maintain the confidentiality of inmate medical records. We only release
medical records if certain legal requirements are met, including requirements set out in HIPAA
(the Health Insurance Portability and Accountability Act). We usually receive requests for
medical records from one of four types of requestors: (1) Social Security, state disability, or
other government benefits agencies; (2) lawyers, inmate friends, or inmate family members; (3)
inmates; or (4) medical providers.
1.
Social Security, State Disability, or other government benefits agencies: These requests
generally ask that medical records be faxed directly to the requesting agency by the facility.
Because of the volume of these types of requests, we ask that they be handled by our staff in

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the facility. If the request is accompanied by a valid authorization, medical staff should fulfill the
request by faxing records as directed. You do not have to send these requests to Risk
Management; you do not have to let us know when you have received or completed one. We
do not track this category of records requests, but we do expect facility staff to comply with them
whenever practical.
2.
Lawyers, inmate friends or family, or other third parties: For all other types of medical
records request (except for medical providers, see below), the procedure is as follows:
a.
Forward the medical records request to the corporate office, Risk Management
Department and we will ensure the authorization is legally adequate, or will send an
authorization to the requesting party to have it completed.
b.
Upon the verification of the medical record request, Risk Management will contact the
facility medical staff to obtain a copy of the required records in accordance with the request. As
Southern Health Partners is able to charge for copies of the medical records in accordance with
state statute, Risk Management will handle the procurement of such.
Standardizing medical records requests in this way allows us to keep track of these requests
and to obtain payment for providing the records. It also takes primary responsibility for dealing
with most requests off the facility medical staff and puts it on Risk Management, which should
reduce the non-medical workload of facility staff.
If you are asked by an inmate or third party how to obtain medical records, you should explain
the procedure to them. You may provide it them with a copy of the “Authorization for Release of
Medical Records,” which is attached, though you also may tell them to obtain one from the
corporate office. Please furnish any requesting party with the corporate address and telephone
number, as well as the name of the person they should contact for medical records.
3.
Inmate requests for records: Southern Health Partners does not provide medical
records to inmates who are currently incarcerated in the facility.
4.
Medical providers requesting records: We are not required to have a patient
authorization to provide medical records to, or receive medical records from, another treating
healthcare provider. If you receive a request for records from a healthcare provider who is a
treatment provider to the inmate, as listed upon intake and/or in the H&P, even if the request
doesn’t have an authorization, you may fill the request. You don’t need to let Risk Management
know you received it and handled it. But if the request comes from a medical provider who is
not a treatment provider to the inmate – for example, a physician conducting a records review
for an attorney, or a counselor seeking to evaluate the inmate for non-treatment reasons – then
you should promptly forward the request to Risk Management. If you have any questions as to
whether the requesting party is a treatment provider, contact Risk Management for assistance.
In order to avoid a delay in obtaining medical records from treating physicians obtain and
forward the inmate’s/patients authorization. We do not require authorizations before sending
records to other current treating medical providers. You will need to document in the medical
record when a copy of the record has been released and what was sent.

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LEGAL PROCESS/LAWSUITS/CLAIMS
If you receive any legal papers of any kind, immediately initial and date the first page as a
record of when you received them. Some legal deadlines begin to run when the legal papers
are received, so it is important to initial and date these documents to establish when you
received them. FAX all legal papers to Risk Management along with a short explanation of how
you got them – i.e., received through the mail, handed to you by a process server, given to you
by jail administration.
Lawsuits: A lawsuit is a legal case that is filed in a court alleging that the facility, Southern
Health Partners, or jail medical staff have done something wrong, for which the person filing the
suit should be compensated. Lawsuits are frequently accompanied by a second document
called a “Summons,” which is a formal notification of suit. Lawsuits may be represented (filed
by a lawyer on behalf of the plaintiff) or unrepresented (filed by the person him- or herself,
without a lawyer). All lawsuits are handled the same way by the company.
If you receive a lawsuit, call Risk Management to let us know. Fax the lawsuit to Risk
Management as soon as possible, and put the original in the mail to us as well. You may
receive several documents along with the lawsuit or complaint, such as a summons, motions, or
court orders. You must fax and send everything that you receive; if you receive a packet
of papers, you must send the entire packet along. If you are named in the suit, you may
keep a copy of the suit for your records.
Immediately make a copy of the patient’s medical file and send a copy of the medical record to
Risk Management. It is important to copy the medical file upon receipt as the jail or jail
administration may also be named in the suit and they may take the medical file to review. It is
easier to copy the file while you still have it than to have to get it back to make a copy.
If you are named as a defendant or a witness in a lawsuit, you will be contacted by an attorney
hired by SHP to defend the case that involves you. You are expected to communicate truthfully
with the attorney and to cooperate fully in the defense of the case. If you have any questions
about the lawsuit or the legal process, feel free to call Risk Management at any time.
Even if you are named as a defendant in a lawsuit, it is important to maintain professionalism in
the workplace at all times. Every inmate is entitled to receive effective and professional
care, and you may not treat an inmate differently because he or she has filed a lawsuit
against you or our company, nor may you allow others to do so. It can be very frustrating
to find that someone you have tried to help has made accusations against you, but it is SHP’s
expectation that you will always give every inmate the same high degree of care.
Subpoenas and Court Orders:
A subpoena is a legal document that requires the person receiving it to appear in court to testify
in a legal matter, or to produce documents to be reviewed in a legal matter. A court order is a
directive issued by a court that requires the person receiving it to immediately do what the order
directs.

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Partners
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If you receive a subpoena or a court order, you must notify Risk Management
immediately. We will assist you in responding appropriately to these legal papers, either by
complying with them or by explaining on your behalf why we cannot comply.
Most subpoenas our staff receives direct them to come to court during an inmate’s trial to testify
to the inmate’s medical care. Most of these subpoenas also require the staff to bring the
inmate’s medical records. In many cases, we can produce a complete and authenticated copy
of the medical record in a manner acceptable to the court, avoiding testimony. If you are
ordered to testify, Risk Management can tell you what to expect, provide advice on how to
conduct yourself, and answer any questions you might have.
Most court orders we receive direct our company to provide an inmate with specific medical
care, such as a particular medication or a particular procedure Often the judge has only heard
from the inmate’s lawyer before signing the order. He or she doesn’t know why our staff isn’t
giving that inmate the particular medication or not ordering the particular procedure. In many
cases, we can explain to the judge why the care the inmate is currently receiving is appropriate,
and have the court order changed or rescinded. But these efforts, if appropriate, are made by
Risk Management, not by facility staff, so it is important that you immediately notify Risk
Management of any court order you receive.

Remember WHERE you work!
SHP encourages and promotes a safe working environment for all SHP staff on-site at the jail.
Remember where you are, you are working in a jail. The medical office/unit is to be nonconfrontational zone. Be secure of yourself and your surrounding work items.
Nurses and/or medical staff should never be involved in securing or restraining an inmate. Call
an Officer!
The following are mandates from Southern Health Partners to all employees:











Do NOT provoke an inmate.
Do NOT give an inmate contraband (check with your jail as to what contraband consists
off, every jail is different)
Do NOT enter into a personal relationship with an inmate.
Do NOT put your hands through a door slot or inside the bars. Let the inmate put his
hands out to you. Always know your safe distance.
Do NOT tell an inmate of appointment times, appointment dates, etc. Inmates plan
escapes.
Do NOT give your full name to an inmate. Our name badges should be written as
“Nurse Judy”.
Always maintain knowledge of and/or location and possession of your keys.
Several jails have inmate trustees emptying trash. Beware of what we think of innocent
items which can be used as weapons.
Limit the use of Ace bandages and/or medical tape; they too can be used as weapons.
In the event of an emergency, do not go into a cell until the officers have it secured. The
officers do not need to worry about you in an unsecured situation when they are dealing

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Partners
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

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
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with an inmate’s situation. They will call you when they need you. When you hear of a
confrontation between officers and inmates or inmates to inmates, stay out of site. They
will call you when and if they need you.
If there are situations where inmates can get to the medical unit (trustees, work release,
etc.), always have a radio or a hot switch in your unit or in your pocket for cases of
emergencies.
Always let the lead officer know when you are leaving the medical unit and where you
are going, and especially when you leave for the day. They get nervous when they don’t
know where you are.
Do alert officers if you feel unsafe. Sometimes a preplan and consistent signal used to
alert your officers can avoid confrontation in your unit.
Do alert your Region Representative(s) or the SHP corporate office Human Resources
Department if you feel unsafe.
Always plan an exit.
Always take a visual survey of your surroundings (pens, rulers, staplers, etc.) especially
when inmates may have to walk through an office area to get to the medical exam room.
Always maintain your role as a medical professional.

HEALTH INFORMATION PATIENT PORTABILITY ACT (HIPAA):
Family Member Calls: You will at one time or another get a phone call from a person claiming
to be an inmate’s family member. Usually this person is distraught – their loved one is in a jail
and they don’t know what is happening with him/her. Be mindful of their situation – they have
only received information about the inmate from the inmate. We know not all statements by an
inmate to family members may be truthful, so be understanding. Be polite, there’s no reason to
be rude. Unfortunately, federal HIPAA regulations prohibit medical information to be released
about a patient. Tell the person “I am sorry, but federal HIPAA guidelines prohibit me from
releasing any medical information about the patient. Please tell me your concerns and I will
look into them. Thank you for your call.” Once you have received the information, document
accordingly and follow up on the information if needed. If a person is belligerent, threatening, or
using foul language, it is ok to tell the caller you cannot talk to them at this time, and ask that
they call your corporate office at 423-553-5635 x935 to discuss the issue(s) in which they are
calling. Further, alert your Medical Team Administrator and/or Jail Administrator of any
threatening phone calls.
Sharing Information – Provider to Provider: There are times when we need to share information
to another medical provider, for continuity of care and the safety of the patient. Please verify
who you are talking with before releasing any information. At times, we ask the caller to fax
something on their letterhead verifying their position. Be mindful of confidentiality.
Calls from the Media: All calls from the media must be directed to the corporate office Risk
Management Department. Do NOT release any information but rather tell the caller all calls
should be directed to the Risk Management Department at 423-553-5635. Be polite.

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Southern Hea]th

Partners
Your Partn er In Afford ab le Inmate Healt hca re

LEGAL QUESTIONS
Risk Management is also your resource for any legal questions you may have. A family
member holding power of attorney for an inmate asks you for information about the inmate:
Should you give out the information? An attorney calls and asks to talk to you: Should you talk
to her? An inmate threatens to sue you: What, if anything, should you do? We can help you
with these types of questions, or with any work-related legal question.
Risk Management can also provide training to medical staff and/or to detention staff on legal
topics, such as confidentiality of inmate health records, medication issues, or legal standards of
care. Let us know if you think such training would be helpful and we will be glad to provide it.
In short, please communicate promptly and fully with Risk Management about any legal topic,
including incidents, reports of inmate deaths, requests for medical records, or lawsuits and legal
process. Please feel free to call Risk Management at any time with any legal concern. We are
a resource for you and will be happy to assist you.

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Partners
Your Partn er In Afford ab le Inmate Healt hca re

INCIDENT REPORT FORM
This form is to be completed by the SHP person identifying the incident and the Medical Team Administrator. The completed
original form must be mailed to the SHP corporate office within 2 working days of the incident. All urgent matters (i.e. deaths,
severe injuries, and lawsuits) must be reported by telephone and/or fax (423-553-5645) to SHP Risk Management immediately.
Site No/Site Name/State
Patient Name
Incident Date/Time/
Place in Jail (Cell,
Kitchen, etc)
Birthdate

Age

I

Sex

I

I

M F

I

Date Incarcerated

I

I

INCIDENT TYPE
Allergic Reaction
Back Injury
Burn
Contraband
Delay in Care/TX
Diabetic Issue
Grievance/Threat of Lawsuit
Head Injury

Hoarding Meds/Items
Extremity Injury
Laceration
Med Error by SHP Staff
MRSA/Staph Infection
Outside Appt Missed/Refused
PREA incident/report
Prior to Booking Injury

Refusal of Treatment
Seizure
Self Injury
Stroke
Suicide Attempt
Work-Detail Injury
Other:

DESCRIBE INCIDENT, USING FACTS:
Seen by/List of those
Involved
Describe Incident
Treatment Given

SAMPLE FORM

Ambulance/ER
Transfer?
Current Disposition
tiou
of Patient?

SEND COPY OF MEDICAL RECORD FOR ANY INCIDENTS WHICH REQUIRE HOSPITALIZATION.
FOR EMPLOYEE/DETENTION
ISSUE ONLY:
Threat to Employee/Staff

Describe Incident – Use Facts – Answer When; Where; How; and Resolution.

Harrassment
Officer Med Pass Error

Your Name/Title:

Date:

Your Contact Information:
Mail originally completed form to: Southern Health Partners, 2030 Hamilton Place Blvd, Ste. 140, Chattanooga, TN 37421
Do NOT file this report in the patient’s medical; Do NOT keep a copy of this report on-site; Do NOT release a copy without the
consent of the SHP Risk Management Department. This is a confidential legal work product of SHP.
Phone: (423) 553-5635 Fax: (423) 553-5645

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Southern Hea]th

Partners
Your Partn er In Afford ab le Inmate Healt hca re

REPORT TO CORPORATE OF INMATE DEATH
Site/Facility:

City/State:

Inmate’s Name:

Incident Date:

Age:

DOB:

Was Inmate a Chronic Care patient:

SS #:

Sex:

Race:

Inmate’s Intake Date to Facility:

Last time/date Inmate was seen by medical staff:

For?

Initial Findings (Note date, time and document inmate position upon finding, condition of body):

Suspected cause of death:
me &
& Title
Title of
of Staff):
Staff):_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Inmate found by: (Name

SAMPLE FORM

Document Incident after finding: (Was CPR started? EMS called? Note date and times)

Jail Staff Notified by Medical (Captain/Jail Administrator - list names):

List Medical Staff Involved and/or notified:

HAVE YOU:

 Contacted Regional Representative  Contacted Corporate Office / Risk Management
 Sent complete copy of medical record to Corporate Office (Attn: Risk Management)

SHP Form updated 9/08

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Southern Hea]th

Partners
Your Partn er In Afford ab le Inmate Healt hca re

AUTHORIZATION FOR RELEASE OF PATIENT MEDICAL RECORD
Patient’s Name: _______________________________________________________________________
Patient’s Address: _____________________________________________________________________
Date of Birth: ____________________________ Social Security Number: _______________________
I, or my authorized representative, request health information regarding my care and treatment be released as set
forth on this form, in accordance with state law, the HIPAA Privacy Rule (45 CFR § 164), and federal law regarding
the disclosure of alcohol and drug abuse patient records (42 CFR part 2).
1.

2.
3.
4.
5.

I understand disclosure of information relating to ALCOHOL AND DRUG TREATMENT, MENTAL HEALTH
TREATMENT except psychotherapy notes, and CONFIDENTIAL HIV-RELATED INFORMATION will be
made if and only if I authorize the release of such information specifically by initialing beside each separate
category set forth below.
I understand I have the right to revoke this authorization at any time in writing, except to the extent that
action has been taken before revocation in reliance on this authorization.
I understand information disclosed under this authorization may be subject to re-disclosure and no longer
protected by federal or state law.
I am signing this release voluntarily, and I understand that my access to health care by this provider will not
be conditioned upon or affected by my authorization of this release.
I understand this release will remain effective for _____ days after signing, unless previously revoked, and I
am entitled to a copy of this form.
I UII I I Vl:,jl l lll l :::_t

l.lllV I V IV"-"V V

l'Vl'l.4 111,11,,ArllJI

Ull\,,t

I

'-"II I UVIVl."-" 1 1U '-111,.,tl, I II J

'-'4VVVVV l-V II V "-"1\.11 VUIIV

IJ

SAMPLE FORM

al Facility:
Facility: ___________________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Correctional
reatment to
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Dates of Treatment
to be Released: ______________________________________________________
Records too be
be Released
Released To
To (Name
(Name and
and Address):
Address): ___________________________________________
_____________________________________________________________________________________

Purpose of Request:

□ Disability Claim □ Legal Issue(s)

□ Continuing Medical Care

Information to be disclosed:
□ Admission Records
□ Complete Medical Record (excluding Include:
□ History & Physical
Alcohol & Drug Treatment, Mental
□ Alcohol & Drug Treatment
□ Medication Records
Health Records, and HIV-related
□ Mental Health Records
□ Physician Orders
Information)
□ HIV-related Information
□ Progress Notes
□ Records from Other
Providers

I have read or been informed of the contents of this authorization and all areas were completed prior to my
signature. I hereby release the facility, Southern Health Partners, and all agents and employees of the
facility and/or Southern Health Partners from any and all legal responsibility or liability for disclosure of
information in reliance upon this release.
__________________________________________
_______________________________________
Signature of Patient or Patient’s Representative
Date
If Representative signs, describe relationship to Patient: ________________________________________

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SHP 000122

 

 

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