History and Physical

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    Continuing on my basic jail nurse questions thread, how many of you, if any, complete some type of history, physical assessment or review of systems form when you assess inmates?

    Since there isn't a form already in place at this facility I want to put something together, or preferably copy someone else's (lol). The existing database allows any employee to view inmate-stated health problems and medications they're on. However, before I do anything to them, or with them, previous healthcare experience suggests I do some element of an assessment, even if only a problem focused assessment (preferable).

    Granted, I'm not looking for some inpatient type of assessment form that goes on ad nauseum since I haven't the time or resources to devote to health issues that inmates don't list on a "sick call" request form or present to the booking officers upon intake and since we're not obligated to treat what isn't made known or whatever may arise in an emergent circumstance.

    So...know where I might find such a beast? Thank you!
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  4. 9 Comments so far...

  5. 1
    type this into google- nursing health assessment form
    SoldierNurse22 likes this.
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    I sense sarcasm. I actually did type that very phrase into Google before coming here. Thanks, nurse2033. It's not my practice to pose discussion questions without first researching the topic I'm asking about.
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    Does the inmate have a history and physical, even brief, upon admission to the facility? We do that, and then do SOAPE charting on each inmate with each encounter. Are you looking for more than that?
  8. 0
    Quote from wyogypsy
    Does the inmate have a history and physical, even brief, upon admission to the facility? We do that, and then do SOAPE charting on each inmate with each encounter. Are you looking for more than that?
    No, there is nothing, and that's why I'm looking for a form. I'm building this from scratch basically. They have a sick call request form in their file and then whatever notes are written up during doctor call including copies of prescriptions.
  9. 0
    I would keep it simple, doing a SOAPE note on what I saw them for and what was discussed during that visit. By doing a head to toe, and learning more about them than you may want to know, you are opening yourself up to liability for taking action on everything you have learned. Always keep in mind that many of these other issues are chronic, that they have not had them taken care of on the streets when they had the ability to do so on their own, and that we cannot fix everyone. Don't open your facility up to liability for 'not' taking care of issues that the inmate might have never brought up unless you specifically asked. I am not trying to be cruel, it is just that if they do not take care of their own health, we can not take it upon ourselves to treat what they themselves have not chosen to feel was important until someone else was paying for it.
  10. 0
    Quote from wyogypsy
    I would keep it simple, doing a SOAPE note on what I saw them for and what was discussed during that visit. By doing a head to toe, and learning more about them than you may want to know, you are opening yourself up to liability for taking action on everything you have learned. Always keep in mind that many of these other issues are chronic, that they have not had them taken care of on the streets when they had the ability to do so on their own, and that we cannot fix everyone. Don't open your facility up to liability for 'not' taking care of issues that the inmate might have never brought up unless you specifically asked. I am not trying to be cruel, it is just that if they do not take care of their own health, we can not take it upon ourselves to treat what they themselves have not chosen to feel was important until someone else was paying for it.
    Thanks for that idea. I agree. I was actually chosen for this job due to prior administration, law enforcement, and hospital nursing experience because previous staff have swamped the facility in litigation, and I'm going in with both RN and LEO credentials (no CO but actual LE) by request. The problem is that although I am intimately familiar this segment of society (criminals and inmates) I have never practiced in let alone managed a clinic. That's why I'm hesitant to jump right in and do a head to toe, etc. I don't want to be obligated to treat something that I found that they (inmates) didn't report. I'm keenly aware that the inmates will use the jail clinic to treat problems that they wouldn't have otherwise treated due to their own since of entitlement as well as seek a pass out of their cell for a day or even an hour. I want to treat their medical issues appropriately, however, I have no desire or intent to give the inmates a bunch of free healthcare for them to take advantage of while they're paying their time.

    I am, however, puzzled by exactly what assessment I should do. For example, as many of them report with toothaches and an assortment of skin bumps, mostly staph infections, should I even delve off into a full set of vital signs, lung sounds, etc? I'm thinking, yes. When I worked back on an ambulance a long time ago we did this on everyone, and when I go to the doctor for the rare health issue this is done in the clinic. It goes without saying that it's done in the hospital, but my jail isn't a hospital so, like I say, I don't know exactly where to draw the line on what is enough assessment in this case. And my only concern is erroneous litigation.
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    Always do a full set of VS with each visit, and rate their pain. Other than that you can just address the issue that they signed up to be seen for. If they come in for athlete's foot, then want to discuss their back pain, and their broken tooth, put a stop to it. They are seen for what they signed up for, if they want seen for something else they need to complete another sick call. I would see them for more than one thing if they put more than that on a sick call but limited it to two requests per sick call slip.

    I would suggest you look at getting a book from the National Commission on Correctional Health Care. This is a wonderful group that was started to ensure (insure?) better healthcare in correctional facilities. Every facility I have worked in, with the exception of the current one, has been accredited. They have a book specifically for jails - Correctional Health Care Standards | National Commission on Correctional Health Care

    I had the great privilege of being audited by the founders of NCCHC. They were amazing. Look at the above website and I think you will find publications that will help you, as well as conferences that you could attend if you so wished.

    Good luck!
  12. 0
    Quote from wyogypsy
    Always do a full set of VS with each visit, and rate their pain. Other than that you can just address the issue that they signed up to be seen for. If they come in for athlete's foot, then want to discuss their back pain, and their broken tooth, put a stop to it. They are seen for what they signed up for, if they want seen for something else they need to complete another sick call. I would see them for more than one thing if they put more than that on a sick call but limited it to two requests per sick call slip.

    I would suggest you look at getting a book from the National Commission on Correctional Health Care. This is a wonderful group that was started to ensure (insure?) better healthcare in correctional facilities. Every facility I have worked in, with the exception of the current one, has been accredited. They have a book specifically for jails - Correctional Health Care Standards | National Commission on Correctional Health Care

    I had the great privilege of being audited by the founders of NCCHC. They were amazing. Look at the above website and I think you will find publications that will help you, as well as conferences that you could attend if you so wished.

    Good luck!
    Thank you!
  13. 0
    Quote from wyogypsy
    I would suggest you look at getting a book from the National Commission on Correctional Health Care. This is a wonderful group that was started to ensure (insure?) better healthcare in correctional facilities. Every facility I have worked in, with the exception of the current one, has been accredited. They have a book specifically for jails - Correctional Health Care Standards | National Commission on Correctional Health Care
    This is sound advice. If you are following NCCHC standards you know that you are on firm footing in whatever policies you develop. I'm not familiar with the jail-specific publication, but I keep copies of the prison-related ones in my office.


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