BOP Program Statement 6090.04 § 2

Each institution will designate one or more individuals, appropriately trained in processing and

maintaining health information, to manage the health record system. These designated staff will

be allowed two hours per quarter for BEMR training. New staff will be trained in these processes

during Introduction to Correctional Techniques and will not receive BEMR access until this

training is complete. Responsibilities include, but need not be limited to:

■ Managing a separate and complete health record for each inmate in an organized, standardized

health record format. Scanning and/or filing results and other required documenta tion in

medical records and assembling patient charts in the required ordering sequence.

■ Maintaining the confidentiality, security, and integrity of all health records and health-related

data.

■ Ensuring the availability and prompt accessibility of the health record to appropriate Health

Services and Psychology Services staff at all times.

■ Participating in quality management/quality improvement activities and functions. This

includes monthly chart audits.

■ Scheduling appointments for patients with other medical services.

a. Medical Referral Centers. Medical Referral Centers will have a credentialed health

information manager on staff or have quarterly audits by a credentialed health information

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manager. Acceptable credentials are to be current through the American Health Information

Management Association (Registered Health Information Technician or Registered Health

Information Administrator) or the Health Information and Management Systems Society

(Certified Professional in Health Information Management Systems).

b. Minimal Equipment Requirements. Each institution must provide sufficient space,

equipment, and supplies to Health Information Management (HIM) staff to enable them to meet

their responsibilities efficiently:

■ Photocopier.

■ Facsimile machine.

■ Desktop computer connected to the LAN with SENTRY access.

■ Scanner with TWAIN driver.

■ Copy of the most recent version of the International Classifications of Diseases, Clinical

Modification.

■ Copies of all applicable Health Services policies.

■ Medical dictionary.

c. System of Records. The Privacy Act of 1974, 5 U.S.C. § 552a, requires the Bureau to give

public notice of the systems of records by publication in the Federal Register. 28 CFR part 16

§51336 specifies, “(a) No Bureau component may contract for the operation of a record system by

or on behalf of the Bureau without the express written approval of the Director or the Director’s

designee.”

Effective January 1, 2009, all available processes within the electronic health record (EHR) are

required for use when documenting patient care, treatment, and services. Records prior to

January 1, 2009, may be documented on paper and filed in a yellow, six-part BOP health record

folder. Contracts with privately managed secure facilities will specify if they are to use the

Bureau’s EHR or the former paper-based records system (see Appendix A).

Medical Referral Centers will maintain a secondary health data index, to include a diagnostic and

operative index. The diagnoses and operations will be coded using the current International

Classification of Diseases, Clinical Modification (ICD-9-CM or ICD-10-CM). The ICD -9-CM

[ICD-10-CM] Official Guidelines for Coding and Reporting will be used for proper code

selection. The index will be maintained (or reviewed quarterly) by a certified professional in health

information. The index will be forwarded to the Chief, Health Information, quarterly.

(1) Filing System for Authorized Paper Records. The health record must be managed so it is

readily available to medical staff at all times.

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Records are filed on open shelves by inmate number according to the numeric Terminal Digit 2

filing system. The files will be divided into 100 sections (00-99). Within each section, the

records are filed numerically by the digits preceding the terminal digit numbers.

An appropriate charge-out system will be maintained when a record is removed from the shelf.

The charge-out system will contain:

■ Inmate name and register number.

■ The date the record is signed out.

■ The location and/or person signing out the record.

All active records charged out must be returned by the end of the workday.

(2) Labels. All authorized paper health record folders must use color-coded numbers affixed to

the right reinforced margin with the following standard Ames® filing colors:

0 – Red

1 − Gray

2 − Blue

3 − Orange

4 − Purple

5 – Black

6 – Yellow

7 – Brown

8 – Pink

9 – Green

■ The size of the labels must be 1 7/8” x 1 7/8” large digit reverse block.

■ Only the last two digits of the first five digits of the register number will be color coded and

placed on the record. For example, register number 12345-678 would have color labels for

45.

■ The fifth digit will be placed at the immediate bottom of the tab on the side of the record

holder.

■ The fourth digit will be placed immediately above the fifth digit label.

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The only additional labels (when necessary) that may be used either on the front cover or within

the health record include:

■ “Allergic to:…” centered beneath BOP Health Record heading.

■ “Advance Directives On File” centered beneath BOP Health Record and allergy label (if

applicable).

■ “Sensitive But Not Classified” on the lower left corner on front cover.

■ Multiple volume labels of a health record will be marked with a white adhesive label located

on the front of the health record in the right upper corner, horizontal, with the label containing

identifying information (i.e., Volume I of II).