BOP Program Statement 6090.04 § 1

To provide guidelines and procedures for health information management in support of the

Bureau’s mission; ensure the health record contains the information needed to justify the inmate’s

care, treatment, and services; and provide continuity of care among providers.

a. Summary of Changes

Policy Rescinded

P6090.03 Health Information Management (7/31/12)

This reissuance incorporates the following modifications:

■ Signature log no longer required.

■ Medical Referral Centers will have a credentialed health information professional on staff or

contract those services (see Section 2.a.).

■ Each facility will have a copy of the most recent version of the International Classification of

Diseases, Clinical Modification (see Section 2.b.).

■ Description of the Bureau’s system of records is referenced in Section 2.c.

■ Applicability of the Health Insurance Portability and Accountability Act (HIPAA) is described

in Section 4.

■ Copies of applicable inmate health records (in lieu of originals) will be taken on escorted

medical trips (see Section 5.b.).

P6090.04 3/2/2015 2

■ Institutions will have an Institution Supplement regarding interruptions to information

processes (see Section 6.).

■ Facilities will use only approved abbreviations in Appendix C.

■ Health record entries will be timely (see Section 7.d.).

■ Procedure for correction of electronic health records is described in Section 7.e.2.

■ Definition of co-signature and review is provided in Section 7.f.1 and 2.

■ All staff-generated forms filed in the record will be in English (see Section 8.a.).

b. Program Objectives. Expected results of this program are:

■ To provide ease of access and availability of information to appropriate health care staff for

persons in the custody of the Bureau.

■ To provide for the maintenance and release of records concerning the medical, mental, and

dental health of persons in the Bureau’s custody.

c. Institution Supplement Required. Implementation of this Program Statement requires

development of an Institution Supplement specifying procedures to manage interruptions to

information processes. Institution Supplement requirements are in Section 6.