U.S. Department of Justice
Federal Bureau of Prisons
PROGRAM STATEMENT
OPI:
HSD/HPB
NUMBER: 6031.04
DATE:
June 3, 2014

Patient Care

/s/

Approved: Charles E. Samuels, Jr.
Director, Federal Bureau of Prisons

1. PURPOSE AND SCOPE
To effectively deliver medically necessary health care to inmates.
a. Summary of Changes
Policy Rescinded
P6031.03
Patient Care (8/23/12)
The following changes were made:
■ Section 15. Added language on the ordering of chronic care medications.
■ Section 18. Replaced use of BP-A0659 (Medical Summary of Federal Prisoner/Alien In
Transit) with BEMR Exit Summary for Inmate Intra-system Transfer.
■ Section 20. Clarified schedule for performing baseline mammographies.

2. PROGRAM OBJECTIVES
The expected result of this program is:

Health care will be delivered to inmates in accordance with proven standards of care without
compromising public safety concerns inherent to the agency’s overall mission.
3. DIRECTIVES REFERENCED
Program Statements
P1070.07
Research (5/12/99)
P1351.05
Release of Information (9/19/02)
P3735.04
Drug Free Workplace (6/30/97)
P4500.09
Trust Fund/Deposit Fund Manual (1/13/14)
P4700.06
Food Service Manual (9/13/11)
P5050.49
Compassionate Release/Reduction in Sentence; Procedures for Implementation of
18 U.S.C. §§ 3582(c)(1)(A) & 4205(g) (8/12/13)
P5280.09
Inmate Furloughs (1/20/11)
P5324.09
Sexually Abusive Behavior Prevention and Intervention Program (8/20/12)
P5324.08
Suicide Prevention Program (4/5/07)
P5521.05
Searches of Housing Units, Inmates, and Inmate Work Areas (6/30/97)
P5553.07
Escapes/Deaths Notifications (2/10/06)
P6010.03
Psychiatric Evaluation and Treatment (8/12/11)
P6010.04
Health Services Administration (6/20/13)
P6013.01
Health Services Quality Improvement (1/15/05)
P6027.01
Health Care Provider Credential Verification, Privileges, and Practice Agreement
Program (1/15/05)
P6070.05
Birth Control, Pregnancy, Child Placement and Abortion (8/9/96)
P6080.01
Autopsies (5/27/94)
P6090.03
Health Information Management (7/31/12)
P6190.04
Infectious Disease Management (6/2/14)
P6270.01
Medical Designations and Referral Services for Federal Prisoners (1/15/05)
P6340.04
Psychiatric Services (1/15/05)
P6360.01
Pharmacy Services (1/15/05)
P6370.01
Laboratory Services (1/15/05)
P6400.02
Dental Services (1/15/05)
Code of Federal Regulations, Chapter 29, Part 1910.95

P6031.04 6/3/2014

2

4. AGENCY ACA ACCREDITATION PROVISIONS
th
■ Standards for Adult Correctional Institutions, 4 Edition: 4-4322M, 4-4344M, 4-4346, 44347, 4-4348, 4-4349, 4-4350, 4-4351M, 4-4352, 4-4353M, 4-4354M, 4-4359M, 4-4360, 44362M, 4-4363M, 4-4365M, 4-4367, 4-4370M, 4-4374, 4-4375, 4-4377, 4-4380M, 44381M, 4-4382M, 4-4389M, 4-4397M, 4-4398, 4-4400M, 4-4401M, 4-4402M, 4-4412, 44426, and 4-4427

■ Performance-Based Standards for Adult Local Detention Facilities, 4th Edition: 4-ALDF-2A45M, 4-ALDF-4A-13M, 4-ALDF-4C-01M, 4-ALDF-4C-03, 4-ALDF-4C-04, 4-ALDF-4C05, 4-ALDF-4C-06, 4-ALDF-4C-08M, 4-ALDF-4C-09, 4-ALDF-4C-13M, 4-ALDF-4C19M, 4-ALDF-4C-20, 4-ALDF-4C-22M, 4-ALDF-4C-23M, 4-ALDF-4C-24M, 4-ALDF-4C26, 4-ALDF-4C-27, 4-ALDF-4C-29M, 4-ALDF-4C-34, 4-ALDF-4C-35, 4-ALDF-4C-37, 4ALDF-4D-01M, 4-ALDF-4D-02M, 4-ALDF-4D-03M, 4-ALDF-4D-15M, 4-ALDF-4D-16,
4-ALDF-4D-17M, and 4-ALDF-4D-18M
■ Standards for Administration of Correctional Agencies, 2nd Edition: 2-CO-1F-14
Records Retention Requirements
Requirements and retention guidance for records and information applicable to this program are
available in the Records and Information Disposition Schedule (RIDS) system in Sallyport.
5. DEFINITIONS
a. Health Services Unit (HSU). The HSU is the organizational unit that provides urgent and
routine health care. In addition, the HSU is the designated part of an institution, including
Medical Referral Centers (MRC) that delivers health care to inmates on an ambulatory or
observation basis. The provision of health care is subdivided into:
■ Urgent Services.
■ Observation Services.
■ Ambulatory Care Services.
b. Outpatient Clinic. This area within the HSU provides diagnostic and other support services
health care staff uses to provide urgent care and ambulatory care services. It includes
examination rooms, treatment rooms, dental clinic, radiology and laboratory areas, pharmacy,
waiting areas, and administrative offices.

P6031.04 6/3/2014

3

c. Observation Area. The observation area provides accommodations of limited duration for
inmates who are being treated for noncritical illnesses, recovering from surgery, or require
observation, and who do not require acute care hospitalization or 24-hour nursing care.
d. Medical Referral Center (MRC). An MRC provides a full range of diagnostic and
therapeutic services, consistent with its individual mission; and a wide range of inpatient
specialty consultative and other services. Inpatient services are available only at MRCs.
The Medical Director will designate each MRC’s mission(s). Each MRC will seek and maintain
accreditation by the Joint Commission for the Accreditation of Healthcare Organizations under
appropriate standards in accordance with its mission. Unless Bureau policy specifies otherwise,
MRCs will organize their programs to comply with Joint Commission standards.
e. Primary Care Provider Team (PCPT). A PCPT is a core group of health care providers
and support staff whose function is to provide direct patient care.
f. Advance Directive. For purposes of this PS, an “advance directive” is a written instrument
(sometimes referred to as a “living will” or other similar document) by which a patient expresses
his/her health care wishes in the event of a terminal or irreversible condition, during which that
individual is no longer able to communicate such wishes to the health care provider due to
incapacitation.
Advance directives may address the patient’s wishes concerning the withholding or withdrawal
of resuscitative, life-sustaining, or other types of medical care.
Advance directives may appoint a proxy decision maker for these type health care decisions.
g. Proxy Decision Maker. For purposes of this PS, a proxy decision maker is a person
authorized to make healthcare treatment decisions for a patient who is incapacitated and unable
to make and/or communicate such decisions himself/herself. The term “proxy decision maker” is
used generally in this PS, and may refer to such person as named in an advance directive,
formally executed power of attorney, or as appointed by a court.
The authority, parameters, and procedures for creating such proxies are governed by the laws of
the state in which the institution operates.
Under no circumstances will another inmate be appointed as proxy decision maker.

P6031.04 6/3/2014

4

h. Life Sustaining or Life Prolonging Procedures. “Life sustaining” or “life prolonging”
procedures include any medical intervention or procedure that uses artificial means to sustain a
vital function or artificially prolong life, e.g. mechanical ventilation, dialysis.
i. Terminal Condition. A “terminal condition” means an incurable or irreversible medical
condition which, in the attending physician’s opinion, is such that death will occur within a short
time regardless of the application of medical procedures.
j. “Do Not Resuscitate” (DNR) Order. A “Do Not Resuscitate” order is the attending
physician’s directive, recorded in the inmate’s health record, to withhold or withdraw
extraordinary life-sustaining measures.
6. PROGRAM RESPONSIBILITY
Clinical care of inmates at Bureau institutions is under the direction of the Clinical Director, who
provides direct patient care and supervises other health care providers. Administrative
responsibility and supervision of non- clinical staff is under the Health Services Administrator’s
(HSA) direction.
7. SCOPE OF SERVICES – CATEGORIES OF CARE
The Bureau of Prisons provides five major levels of care that define care provided to inmates.
Note: Ordinarily, pretrial or non-sentenced inmates, and inmates with less than 12 months to
serve, are ineligible for health services in subsections c., d., and e.
a. Medically Necessary – Acute or Emergent. Medical conditions that are of an immediate,
acute or emergent nature, which without care would cause rapid deterioration of the inmate’s
health, significant irreversible loss of function, or may be life-threatening.
Examples of conditions considered acute or emergent include, but are not limited to:
■
■
■
■
■
■
■

Myocardial infarction.
Severe trauma such as head injuries.
Hemorrhage.
Stroke.
Status asthmaticus.
Precipitous labor or complications associated with pregnancy.
Detached retina, sudden loss of vision.

P6031.04 6/3/2014

5

Treatment for conditions in this category is essential to sustain life or function and warrant
immediate attention.
b. Medically Necessary – Non-Emergent. Medical conditions that are not immediately lifethreatening but which without care the inmate could not be maintained without significant risk
of:
■ Serious deterioration leading to premature death.
■ Significant reduction in the possibility of repair later without present treatment.
■ Significant pain or discomfort which impairs the inmate’s participation in activities of daily
living.
Examples of conditions considered medically necessary, non-emergent include, but are not
limited to:
■ Chronic conditions (diabetes, heart disease, bipolar disorder, schizophrenia).
■ Infectious disorders in which treatment allows for a return to previous state of health or
improved quality of life (HIV, tuberculosis).
■ Cancer.
c. Medically Acceptable – Not Always Necessary. Medical conditions which are considered
elective procedures, when treatment may improve the inmate’s quality of life. Relevant
examples in this category include, but are not limited to:
■ Joint replacement.
■ Reconstruction of the anterior cruciate ligament of the knee.
■ Treatment of non-cancerous skin conditions (e.g. skin tags, lipomas).
These therapeutic interventions always require review by the Institution Utilization Review
Committee. Relevant factors to consider in approving the proposed treatment in this category
include, but are not limited to:
■
■
■
■

The risks and benefits of the treatment.
Available resources.
Natural history of the condition.
The effect of the intervention on inmate functioning in his/her activities of daily living.

d. Limited Medical Value. Medical conditions in which treatment provides little or no medical
value, are not likely to provide substantial long-term gain, or are expressly for the inmate’s

P6031.04 6/3/2014

6

convenience. Procedures in this category are usually excluded from the scope of services
provided to Bureau inmates. Examples in this category include, but are not limited to:
■ Minor conditions that are self-limiting.
■ Cosmetic procedures (e.g. blepharoplasty).
■ Removal of non-cancerous skin lesions.
Any treatment in this category which a health care provider recommends and the Clinical
Director feels is appropriate will require the Institution Utilization Review Committee’s review.
e. Extraordinary. Medical interventions are deemed extraordinary if they affect the life of
another individual, such as organ transplantation, or are considered investigational in nature.
Any treatment provided in this category requires the Medical Director’s review and approval
with notification to the Regional Director.
8. UTILIZATION REVIEW
Every institution will have an established Utilization Review Committee (URC), chaired by the
Clinical Director. Other members should include, but not be limited to the:
■
■
■
■
■

HSA or Assistant HSA.
Medical Trip Coordinator.
Health care provider(s) directly involved in the reviewed cases.
Director of Nursing (if applicable).
A chaplain or social worker.

The URC will review the following areas:
■ Outside medical, surgical, and dental procedures.
■ Requests for specialist evaluations, in-house or escorted trips to the specialist’s office
(approved by the Clinical Director).
■ Requests for “Limited Medical Value” treatments/procedures (approved by the CD).
■ Retrospective review of all cases sent to the community hospital during hours when no health
care provider was on duty at the institution.
■ Case considerations for extraordinary care.
■ Concurrent review of inpatients at community hospital (monitoring length of stay and
interventions).
■ Other services the primary care provider or the Clinical Director have recommended.

P6031.04 6/3/2014

7

Note: Care considered “Medically Necessary – Acute or Emergent” does not require URC
review prior to the treatment being provided.
a. Recommendations. The URC must select one or more of the following, to address each case
presented to it:
■
■
■
■

Approve the request without modification.
Refer the inmate for further evaluation to a staff physician.
Refer the inmate for further evaluation to a specialty consultant.
Put the inmate on a waiting list, with recommended parameters as to the length of time the
procedure may be delayed without increasing the risk of additional morbidity.
■ Determine that the procedure is contraindicated, due to unacceptable risk to the inmate if it is
performed.
■ Deny the request for the procedure.
b. Decisions. As chair of the committee, the Clinical Director is the final authority for all URC
decisions.
The CD will notify inmates in writing when URC decisions are made with a copy of the
notification placed in the inmate’s health record. The reason for the decision should be indicated
where applicable.
The CD is under no obligation to follow consultant recommendations. If the recommendations
are not followed, the CD will document his/her justification in the inmate health record.
If a specific intervention is not pursued, the inmate will be advised that his/her condition will
continue to be monitored and ongoing treatment provided as necessary, and that re-submission of
the request will be considered if medically indicated.
c. Secondary Reviews. The Clinical Director may request a secondary review for treatments or
procedures in the categories of “Medically Acceptable – Not Always Necessary” and “Limited
Medical Value” on a case-by-case basis through the regional Clinical Specialty Consultants or a
Central Office physician. The CD will document such discussions in the inmate health record.
d. Pre-certification. The Medical Director may periodically require pre-certification (prior
approval) for certain types of cases (e.g. high risk, high cost, or questionable efficacy).
Institutions will be notified by memorandum when pre- certification requirements are in effect.
e. Retrospective Review. Institutions should consider a retrospective review of emergency
cases based on URC findings as part of the institution Quality Improvement Program.
P6031.04 6/3/2014

8

9. EMERGENCY/URGENT CARE
Each institution will have an Institution Supplement for providing 24 hour medical, dental and
mental health care. Each supplement will include procedures for notifying the HSU for initial
assistance, screening and, if appropriate, subsequent transfer of the inmate(s) to the HSU or to
external emergency facilities. The procedures will address:
■
■
■
■

Arrangements for on-site first aid and crisis intervention.
Use of one or more HSU urgent treatment rooms or other facilities.
Use of the HSU emergency medical vehicle for transporting inmates across the compound.
Appropriate method of transfer of the inmate from the institution to a community medical
facility.
■ Provision of emergency treatment in the absence of 24 hour on-site medical coverage.
■ Emergency on-call procedures for hours that health care providers are not on-site.
ACA standards require a four-minute response to life- or limb-threatening medical emergencies.
Institutions without 24-hour on-site medical coverage, or those with multiple facilities separated
by significant distance, are required to have procedures incorporated into the institution
supplement by which this ACA standard can be met.
A team of “first responders” should be established for each shift, with documented training in
first aid and CPR. Numbers on each team, and the designation of team members, will be
negotiated locally:
■ Use of one or more designated hospital emergency rooms or other appropriate facilities.
■ Emergency on-call physician, dentist, and mental health professional services when the
emergency health facility is not located in a nearby community.
■ Security procedures providing for the immediate transfer of inmates when appropriate.
The HSU will conduct two emergency disaster drills per year. All drills will be critiqued to
identify deficiencies and opportunities to improve. Documentation will be maintained in the
HSA’s office.
At MRC’s, compliance with ACA and Joint Commission standards will be considered sufficient
to meet the above requirements.
All health care practitioners, including HSAs and AHSAs, and Lieutenants will maintain CPR
and Automated External Defibrillator (AED) certification. The HSA will be responsible for
P6031.04 6/3/2014

9

maintenance and supplies (unexpired pacing pads/electrodes) for the AED according to the
manufacturer’s recommendations. Other staff may request CPR/AED training.
Annual review of the above supplement will be done during initial orientation to the HSU and
annually thereafter.
Annual review of this supplement will be considered as part of in-house Continuing Professional
Education.
10. OBSERVATION SERVICES
Institutions may provide limited observation bed space. These beds are not used in lieu of
transfer to a community hospital or MRC. Observation beds will only provide limited outpatient
services for short stay inmates.
Observation beds are located in the HSU. Neither patient examination rooms nor the Urgent
Care Room will be used as observation rooms. Inmates placed on observation status do not
require medical treatment(s) normally provided in an MRC or community hospital setting.
a. Written Procedures Required. Each institution using observation beds will have written
procedures delineating their use, conforming to this policy. These policies will include
procedures for:
■
■
■
■
■
■
■

Designation of physical location of observation beds.
Evaluation.
Level of care provided.
Supervision requirements.
Release of inmates from observation beds.
Sight and sound requirements (i.e. nurse call systems or visual monitoring systems).
Direct observation every 30 minutes.

If the sight and sound requirements cannot be met by call buttons, electronic monitoring, or
direct observation, then observation beds will not be used.
b. Operations. Observation rooms may only be used in accordance with the following:
■ Only a physician may authorize their use when the room is used for medical observation. (If
the room is used for suicide prevention, all requirements of the Program Statement Suicide
Prevention Program apply).

P6031.04 6/3/2014

10

■ The Clinical Director will notify the Warden and other appropriate institution staff of the
inmate’s observation status.
■ The CD will advise the Warden on the inmate’s medical status and monitoring
recommendations.
■ The institution will have a plan to transfer the inmate to a community hospital in an
emergency situation.
■ The inmate will be oriented to life safety and fire evacuation procedures of the unit.
c. Initiation and Discontinuation. The following procedures apply to the initiation and
discontinuation of observation status.
■ A physician must be on call 24 hours per day.
■ A physician will write an order on the Chronological Record of Medical Care (SF-600)
admitting an inmate to observation status.
■ When the physician authorizes use of medical observation telephonically, the physician must
evaluate the inmate personally within four hours.
■ All encounters between the inmate on observation and a health care provider will be recorded
on an SF-600 form.
■ Vital signs (temperature, blood pressure, pulse, respiration, pulse oximetry, if indicated) will
be ordered by the physician and recorded on any inmate upon initiation of observation status,
and daily thereafter, or as clinically indicated.
■ Other diagnostic procedures such as laboratory tests, radiographs, etc. will be ordered, as
indicated, by the physician.
■ The Medical Duty Officer/physician on call will evaluate the inmate personally once daily,
including weekends and holidays.
■ Observation status may only be discontinued by a physician, ideally by the same physician
who authorized the observation.
d. Appropriate Use. HSU observation rooms may be used in cases that do not require 24-hour
nursing care, such as an inmate recovering from a surgical procedure in the local community, or
to ensure that an inmate is prepared properly for a medical/dental procedure. Examples of
appropriate observation room use include:
■ Preparation of inmates for diagnostic studies such as upper/lower G.I. series, fasting
purposes, etc.
■ Upon return from out-patient surgery to assist adjustment in use of crutches, cane, casts, etc.
Control of pain associated with known kidney stones.
■ 24-hour urine collection, e.g. if the urine requires refrigeration.
■ Ruling out infectious hepatitis (hepatitis A) requires isolation procedures.

P6031.04 6/3/2014

11

■ Routine postoperative care such as indwelling catheters (status post prostate surgery), or
surgical drains.
A physician will review the need for continued observation after the first 24 hours. Inmates may
only remain in observation status for 72 hours.
Observation rooms will never be used (not all inclusive):
■
■
■
■
■

To rule out myocardial infarction.
For inmates suddenly incontinent of bowel or urine.
To rule out stroke.
For acute mental health changes.
For mental health diagnoses (placement of a mental health inmate in a locked room
constitutes seclusion and other requirements apply).
■ For reasons that may be deemed punitive such as restricting the inmate from recreation and
other activities due to continued complaints such as back pain, etc.
11. NEGATIVE PRESSURE ISOLATION ROOMS (NPIR)
Infectious Disease Isolation Rooms are negative air pressure-capable rooms constructed and
operated in accordance with Centers for Disease Control (CDC) guidelines.
The CD will determine the length of stay for an inmate assigned to negative pressure isolation
with tuberculosis, chickenpox, herpes zoster, or other infections requiring air-borne precautions.
The CD will consult with the Medical Director for guidance on medications, length of stay, and
contact investigations. See the Program Statement on Infectious Disease Management.
The Medical Director will determine which institutions must maintain certified Negative
Pressure Isolation Rooms.
Institutions without these rooms will have a local procedure for immediate transfer of inmates
with suspected active tuberculosis or other highly contagious airborne diseases to a community
hospital or other BOP institution within close proximity with NPIR capability.
12. AMBULATORY CARE SERVICES
Each institution will have written policies and/or procedures for providing ambulatory care
services. Procedures for the Outpatient Department will include at least:
P6031.04 6/3/2014

12

■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■

Management of inmates with mental illnesses or disorders.
Patient privacy.
Infection control.
Poison control.
CPR.
Patient triage/sick call procedures.
Medical duty status.
Treatment of patients in special housing units and detention status.
Intake screening.
Urgent treatment.
Staffing (describing implementation of the PCPT model).
Chronic care clinics.
Accident reporting.
Advance directives.
Autopsies.
EKG (including procedures to obtain stat interpretations).
Physical examinations.
Eyeglasses.

a. Primary Care Provider Teams. The PCPT is designed to improve health care services
delivery by enhancing continuity of care and promoting preventive health care measures. The
PCPT is designed to function in the same manner as a medical office in a community setting.
Under the PCPT model, each inmate is assigned to a medical team of health care providers and
support staff who are responsible for managing the inmate’s health care needs.
Assigning inmate caseloads to PCPTs will provide less duplication of services because team
members will be more familiar with the medical problems of inmates assigned to the team.
Adequate numbers of mid-level providers (MLP) need to be available to provide diagnostic and
treatment services to the inmate population during the typical weekday hours when the bulk of
health care is delivered in our institutions.
For this model to be effective, teams are designed with support staff, such as nurses, medical
assistants, health information technicians, and medical clerical staff, to perform duties and
services which support the MLPs and physicians as they see their patients in the clinic.
Virtually all patient care provided to inmates will be by appointment, scheduled several days to
weeks in advance through requests from the inmate, or follow-up appointments determined by
the providers. When fully implemented, “sick call” will be eliminated (see Section 17).
P6031.04 6/3/2014

13

Administrative facilities [Metropolitan Correctional Centers (MCC), Metropolitan Detention
Centers (MDC), Federal Detention Centers (FDC), the Federal Transportation Center (FTC)] and
MRCs, although not required, may establish PCPTs. The staffing pattern and provider/inmate
ratios may be different based on patient acuity levels at administrative facilities.
Administrative and non-clinical functions supporting the HSU (e.g. budget, infection control,
quality improvement activities, pharmacy services, laboratory and x-ray services and the
ordering of supplies) will be performed by staff other than PCPT staff.
PCPT staff may participate in HSU committees and meetings which relate to patient care.
Appropriate levels of support staff must be achieved when implementing PCPT.
Institutions are to assign inmates to health care providers fairly and equitably. The method of
assigning inmates will be negotiated locally.
Achieving this model will occur at different rates for different institutions. Factors affecting this
rate of change include:
■
■
■
■
■
■

Current staffing patterns.
Unique institution missions and populations.
Staff attrition.
Ability to recruit and retain the desired mix of staff.
Adequate administrative support staff.
Adequate numbers of examination rooms, consultant rooms, equipment, etc.

Each institution must develop a contingency plan to address staff shortages which may occur
after implementation of PCPT. Implementation will be negotiated locally.
When implementing the PCPT model, the following general guidelines should be considered for
existing institutions:
(1) Staffing Pattern. Each institution will assess the current health services staffing pattern and
restructuring plan. For example, a day shift PCPT staffing pattern for 1,000 general population
inmates will have one physician, three mid-level practitioners, a registered nurse, one or two
licensed practical nurses and/or medical assistants, two health information technicians, and a
medical clerical staff person. Based on this example, each MLP would be assigned a caseload of
approximately 330 inmates.

P6031.04 6/3/2014

14

Insufficient staffing will have an adverse effect on the quality, continuity, and cost-effectiveness
of health care.
Additional staffing will be required to provide health care services after hours and on weekends.
Additional staff and posts will be required for most satellite camps as well as satellite FDCs and
WITSEC Units.
The provider-to-inmate ratio may also need to be adjusted depending on institution’s security
level, physical layout, and mission.
For a 1,000-bed female institution, one additional mid-level practitioner and one additional
female clinical support person for chaperone purposes will be required.
(a) Physician. A physician will provide clinical oversight for multiple provider teams. The
physician, as the licensed provider of the team, is responsible for the care that team delivers. As
such, it is the physician’s responsibility:
■ To consult with the other team members.
■ To provide training and mentoring.
■ To directly evaluate and treat severely ill and medically complex inmates.
While the MLP is the PCPT’s primary care provider, physicians are also responsible for
providing direct patient care. Physicians will medically manage inmates with complex conditions
on an ongoing basis notwithstanding the assignment of that inmate to an MLP. (Refer to Section
15 for discussion of the physician’s role and referral procedures for complex conditions).
(b) Mid-level Practitioner (MLP). The MLP will serve as the primary point of contact for
inmates assigned to their caseload. They will serve as the primary provider for:
■ Routine requests for evaluation of new complaints.
■ Ongoing management of reoccurring conditions.
■ Emergencies when clinically indicated.
Refer to Section 15 for the MLP’s role in Chronic Care Clinics.
(c) Clinical Nurse (RN). When the PCPT model is implemented, the Clinical Nurse will serve
as the coordinator for the out-patient area. Duties will include but not be limited to:

P6031.04 6/3/2014

15

■
■
■
■

Managing patient flow and triage.
Responding to institution emergencies with MLP or physician back up.
Coordinating the workload/duties of the Licensed Practical/Vocational Nurse (LPN/LVN).
Screening new arrivals and assessing inmates returning from consultant visits or
hospitalizations.
■ Providing patient education, etc.
(d) Licensed Practical/Vocational Nurse (LPN/LVN). The LPN/LVN, who is accountable to
the RN, will provide healthcare support for other clinical staff. LPN/LVN duties will include but
not be limited to:
■
■
■
■

Collecting patient information including vital signs and blood pressure checks.
Providing dressing changes.
Administering treatments and/or medications.
Performing EKGs, etc.

(e) Health Information Technician (HIT). The HIT will obtain medical records for the health
care providers. Other duties will include:
■ Entering SMD data.
■ Filing lab/x-ray/consultant reports.
■ Scheduling consultant visits, etc.
(f) Medical Clerical Staff. Clerical staff will be responsible for:
■
■
■
■
■

Ordering/stocking forms and supplies in the examination and treatment rooms.
Answering the telephone.
Locating inmates who do not report for scheduled appointments.
Clerical support for the PCPT.
Assisting with SMD entry, entering call-outs, etc.

(2) After-Hour Coverage. After-hour, weekend, and holiday coverage will be provided by
registered nurses and/or EMTs, where available, based on the institution’s hours of in-house
health care staff coverage.
An MLP may, under special circumstances, be assigned to evening and weekend coverage at
institutions/complexes where the institution’s size and complexity warrants.
Local procedures will be established to provide for emergencies including:

P6031.04 6/3/2014

16

■ Calls from institution staff requesting an emergency appointment for an inmate during day
watch, Monday-Friday. In this situation, typically, triage will be conducted by the team’s
registered nurse and the inmate’s primary MLP would see the inmate if necessary.
■ Significant medical emergencies such as trauma, heart attack, asthma attack, etc. will be
treated immediately by appropriate team members.
(3) Vacancies. As Health Services vacancies occur, each vacancy should be evaluated carefully
to determine the best type of provider to hire to implement the PCPT model.
Institutions are encouraged to fill these positions with appropriate Bureau staff through the
Priority Placement Program, Merit Promotion Plan, voluntary transfer, Public Health Service
(PHS), etc.
Activating institutions will develop a Health Services staffing pattern consistent with the PCPT
model.
13. SPECIAL HOUSING UNITS (SHU)
All Health Services Units will have procedures and control systems to ensure continuity of
medical and psychiatric care and treatment for inmates housed in SHUs. Health care staff will be
informed immediately when an inmate is transferred to SHU. Procedures will be determined
locally.
Local procedures will include at least the following:
■ Protocols to provide for the assessment and review of inmates transferred to SHU.
■ A health care provider will make daily rounds during the “lights on” period, except in
extenuating circumstances. These rounds will be announced and recorded on the Special
Housing Unit Record (BP-A0292).
■ A mechanism describing how SHU inmates will notify medical staff of their need for health
care.
■ Daily rounds to triage urgent requests for care (should be accomplished by the same staff
member who conducts the morning pill line in SHU, typically an RN/LPN/LVN).
■ Procedures for follow-up care by an MLP or physician. All SHU inmate encounters,
including medication refills or dispensing of over-the-counter medications, will be
documented in the inmate health record.
The health record should be available when a SHU inmate is examined or treated for all but the
most minor of conditions, if possible.

P6031.04 6/3/2014

17

Health care staff will take particular care to monitor any inmate who is a potential suicide risk.
See the Program Statement Suicide Prevention Program.
14. REFERRAL PROCEDURES BETWEEN HEALTH CARE PROVIDERS
Each institution will develop and maintain a log book (or equivalent computerized tracking
system available to all HSU staff) to facilitate referrals between health care providers and the
physician. Recommended elements of this log include:
■
■
■
■
■
■
■
■
■

Date of referral.
Register number.
Inmate last name, first name.
Referring provider.
Referred to Dr.
.
Reason for referral.
Date referral noted by physician, with physician’s initials.
Date inmate to be seen by physician.
Date seen by physician.

Inmates who are evaluated by an MLP on three separate occasions, without a definitive diagnosis
or response to treatment, will be referred to a physician for evaluation.
15. CHRONIC CARE CLINICS
Chronic Care Clinics (CCCs) are a means for inmates with ongoing medical needs to be tracked
and seen by a health care provider at clinically appropriate intervals. A physician will see all
inmates assigned to a CCC every 12 months, or more often if clinically indicated.
The frequency of CCC follow-up care will be determined based on clinical need and
communicated to the inmate’s primary MLP, who will provide this care.
The physician will review the health records of all CCC follow-up encounters the MLPs
perform.
High risk or medically complex chronic care inmates will be seen more frequently in accordance
with good clinical judgment, in addition to or in conjunction with regular visits with their
primary provider.

P6031.04 6/3/2014

18

All treatment and management decisions a physician or MLP make will be communicated to the
inmate’s assigned primary provider for continuity of care.
The CD or staff physician will:
■ Initially examine all new arrivals from other institutions that have a CCC assignment, within
14 days of arrival, to establish a treatment plan and follow-up intervals appropriate for the
inmate’s medical needs.
■ Personally examine and approve all additions and deletions of inmates to a CCC.
The CD retains overall professional responsibility for managing CCC inmates. The CD is
expected to provide consultation to the MLPs as needed.
Prescribers may order chronic care medications for up to 365 days, except with the limitations
outlined in the National Drug Formulary. Inmates chronically taking medications that cannot be
prescribed for 365 days will be followed by a physician.
16. DOCUMENTATION
The HSA will ensure that a Bureau approved tracking system is maintained and is accessible to
all Health Services Staff, to ensure identification and follow-up of patients assigned to CCCs.
Generally, inmates should not be placed in separate clinics to address various conditions (e.g., a
diabetic patient with angina and high cholesterol should be seen on only one CCC (primary
diagnosis) and all relevant issues addressed at each visit).
In some cases, it is appropriate to assign an inmate to multiple clinics if this allows better
tracking for follow-up by outside specialists, e.g. psychiatrists and infectious disease consultants.
CCC visits will be documented on the Chronological Record of Medical Care (SF-600) using the
SOAP format (see below.)
CCC entries will be preceded by a block stamp identifying the note as “Chronic Care Clinic,” or
a specific condition such as “Diabetic Clinic” or “Mental Health Clinic.”
All Progress Notes must be legible and written in black or dark blue ink.
a. SOAP Format. Patient encounters will be documented using the SOAP format:

P6031.04 6/3/2014

19

S-Subjective or Symptomatic data.
O-Objective Data.
A-Assessment.
P-Plan.
Patient education is a required element of the treatment plan. Education may be documented
under “P,” or may be documented separately (“SOAPE”).
Patients who complain of pain, will be assessed and treated if necessary.
b. Administrative Notes. Administrative notes are notes placed on the SF-600 to document
issues important to the inmate’s care when the inmate is not seen by the provider at the time of
the entry, such as:
■
■
■
■
■

Review of laboratory and radiology results.
Review of consultant reports.
CD updates on an inmate’s status in the community hospital.
Medication refills not related to a clinic visit.
Instances when the inmate is not examined or does not report for a scheduled appointment.

c. Request for Consultation. All requests for consultation by an outside consultant or contract
health care provider must be in writing on the Consultation Sheet form (SF-513). Sufficient
clinical information should be provided at the top of the SF-513, or by attaching copies of
documents from the inmate health record, to describe the inmate’s complaint or condition, and
the information being sought by the referring physician.
The CD, or designee, must review and approve all requests for consultation by a specialist prior
to the consultation.
It is expected that a staff physician will have examined most inmates referred to an outside
consultant.
All encounters by consultant providers will be documented on the SF-513. Transcribed
consultation reports will be filed with the SF-513.
Contract consultants who evaluate inmates within the institution will not document on the
Progress Notes.
All consultation reports will be reviewed, co-signed and dated by the Clinical Director or staff
physician.
P6031.04 6/3/2014

20

Bureau physicians are not obligated to follow all consultant recommendations. If a consultant
makes a recommendation which is outside Bureau policy or scope of services, the CD will
document thoroughly the reasons the consultant’s recommendations are not followed, based on
input from the staff physician.
17. TRIAGE/ACCESS TO CARE
Triage is defined as the classification of patients according to priority of need for examination
and/or treatment. Triage allows truly urgent conditions to be addressed adequately on the same
day, while also allowing more routine conditions or concerns to be addressed at a scheduled
appointment. During triage the following will occur:
■ The inmate will provide a brief history.
■ Vital signs will be taken, if indicated.
■ An appointment will be scheduled with the appropriate provider within a time frame
appropriate for the inmate’s condition and medical needs.
■ If no follow-up appointment is warranted, the inmate will be advised of other options (e.g.
obtaining over-the-counter medications from the Commissary, submitting an Inmate Request
to Staff (BP-A0148), etc.
An Inmate Request for Triage Services will be completed for each inmate. The form is to be preprinted onto an SF-600. These forms will be filed in Section 1 of the inmate health record.
If no appointment is scheduled as a result of triage, this will be noted on the triage form and will
be turned in to the Health Information Department for filing.
a. Appointments. Virtually all clinical services provided to the inmates will be by appointment,
scheduled several days to weeks in advance through a request from the inmate or follow-up
appointments determined by the providers.
Institutions not yet implementing the full PCPT model will use the triage system described
above.
Inmates may request clinical services on a daily basis by completing the Inmate Request for
Triage Services form. Health Services staff will triage and prioritize the requests and schedule
appointments based on need.

P6031.04 6/3/2014

21

Physicians and other health care providers will be available five days per week to provide
clinical services.
Urgent Care services (injuries, chest pain, asthma attacks) will be available at all times, either
through on-site providers or community emergency services.
b. Examination Areas. Staff will see inmates individually in a private examination area. Other
inmates will not be present, except in emergencies or other unusual circumstances (i.e., as a
translator when staff interpreters are not available).
Ordinarily, the examiner will have the inmate’s health record during all inmate visits. If the
health record is not available for a routine examination, the inmate should be rescheduled. Staff
will document the reason the health record was not available.
The examining room will have adequate space (minimum of 100 sq. ft.), running water, and
provision for both the examiner and inmate to be seated.
There will be adequate desk space so that the examiner may make notes in the inmate health
record.
Necessary forms, equipment, and supplies, including an examining table will be available.
A sharps bio-hazard disposal container, mounted to the wall if possible, will be located in all
rooms where needles and syringes are used.
Appropriately labeled bio-hazardous waste containers will be available.
Examination rooms will be cleaned regularly including the disinfection of examination tables
and contaminated surfaces. Inmate orderlies may perform this task.
Between each patient, the examination table must either be wiped down with a disinfectant or the
table paper must be changed.
When patient encounters are conducted in a satellite area (segregation, special custody units,
industry locations, camps, units with difficult egress, etc.), adequate space and equipment will be
available, consistent with the requirements above.
The SOAP label may be used to document a patient encounter in Special Housing/detention
units in lieu of the inmate’s health record. This label is then affixed to the SF-600.

P6031.04 6/3/2014

22

c. Privacy. Staff will provide inmates the opportunity to discuss their medical complaints
without other inmates being present.
18. INTAKE SCREENING
a. Newly Incarcerated Inmates. Health Services clinical staff will conduct an initial
assessment of each newly committed inmate upon his/her arrival at an institution. This screening
is to determine:
■
■
■
■

Urgent medical, dental, or mental health care needs.
Signs of acute drug or alcohol intoxication or symptoms of withdrawal.
Restrictions on temporary work assignments.
Freedom from contagious infectious disease.

Inmates with perceived immediate medical/dental/mental health needs will be referred to the
appropriate health care staff for evaluation.
b. Bureau Intra-system Transfers. The BEMR Exit Summary for Inmate Intra-system
Transfer will be reviewed and annotated appropriately at each receiving institution, including the
designated institution.
It is prohibited to transfer inmates between Bureau institutions, (including all holdover status
inmates, i.e., DEA, U.S. Marshals Service, Bureau of Immigration and Customs Enforcement
[formerly INS], FBI, etc.), who have not been screened for TB. This prohibition does not apply
to court-related activities or inmates being transferred on writ (to non-Bureau institutions).
It is the HSA’s responsibility to ensure health services staff completing the BEMR Exit
Summary for Inmate Intra-system Transfer have documented TB screening results and that the
inmate is cleared for transfer prior to electronically signing the form.
Transporting officials will not accept any inmate for transfer unless either PPD or chest x-ray
results are completed and satisfactory for transfer, as noted on the BEMR Exit Summary for
Inmate Intra-system Transfer.
19. PHYSICAL EXAMINATIONS
a. Short-Term Examination. For individuals in predictably short-term custody (FDCs/MCCs/
MDCs/Jails), an initial screening physical examination to determine medical needs will be done
within 14 days of admission on the appropriate physical examination form.
P6031.04 6/3/2014

23

However, TB screening must be initiated within two working days of incarceration. (See the
Program Statement Infectious Disease Management.)
Initial screening physical examinations include, but are not limited to, the following components:
(1) Medical and Mental Health. Complete the history and screening physical examination
form(s).
Inmates showing signs of acute drug or alcohol intoxication or withdrawal symptoms will be
managed in accordance with the institution’s local procedure for detoxification of chemically
dependent inmates.
Staff will obtain a detailed history of substance use and conduct an examination.
Health Services staff will complete a written referral to the institution Chief Psychologist and
Clinical Director for any inmate showing evidence of substance dependence/abuse.
(2) Dental. Complete the dental intake screening form(s) in accordance with the Program
Statement Dental Services.
(3) Ordering of appropriate laboratory and diagnostic tests, if clinically indicated. Examples
include hepatitis screening, sickle cell screening (hemoglobin electrophoresis is recommended
over Sickledex), sexually transmitted disease (STD) testing, chest x-ray, EKG. (Refer to the
Program Statement Infectious Disease Management for HIV testing.)
The physical examination is considered complete when the above three steps are completed. The
CD will review and sign the completed physical examination form.
Clinically indicated laboratory test results do not need to be received prior to signing the physical
examination form.
Any abnormal laboratory results generated as part of the physical exam must be documented in
the progress notes.
The inmate must be counseled regarding any necessary follow-up treatment or testing within a
clinically appropriate time frame.

P6031.04 6/3/2014

24

Intra-system transfers do not need a second complete initial physical examination as long as one
has been completed for this period of confinement. Inmates who present any new medical
problems will be assessed appropriately.
b. Long-Term Examination. For individuals in predictably long-term incarceration
(sentenced/designated), an initial complete physical examination to determine medical needs will
be done within 14 days of admission on the appropriate examination forms.
However, TB screening must be initiated within two working days of incarceration. (See the
Program Statement Infectious Disease Management.)
The initial complete physical examination includes, but is not limited to, the following
components:
(1) Medical and Mental Health. Complete the history and physical examination form(s).
Inmates showing signs of acute drug/alcohol intoxication or withdrawal symptoms will be
managed in accordance with the institution’s local procedure for detoxification of chemically
dependent inmates.
Staff will obtain a detailed history of substance use and conduct an examination.
Health Services staff will complete a written referral to the institution Chief Psychologist and
Clinical Director for any inmate showing evidence of substance dependence/abuse.
(2) Dental. Complete the dental examination forms in accordance with the Program Statement
Dental Services.
(3) Ordering of appropriate laboratory and diagnostic tests, if clinically indicated. Examples
include hepatitis screening, sickle cell screening (hemoglobin electrophoresis), STD testing,
chest x-ray, EKG, age-appropriate preventive health examinations. (Refer to the Program
Statement Infectious Disease Management for HIV testing.)
The physical examination is considered complete when the above three steps are completed. The
CD will review and sign the complete physical examination form.
Clinically indicated laboratory test results do not need to be received prior to signing the physical
examination form.

P6031.04 6/3/2014

25

Any abnormal laboratory results generated as part of the physical exam must be documented in
the progress notes.
The inmate must be counseled regarding any necessary follow-up treatment or testing within a
time frame which is clinically appropriate.
The long-term examination policy applies to all Bureau institutions, except as noted above under
the short-term physical examination section. Unless clinically indicated, Health Services staff
does not need to complete a new physical examination on an inmate who has had one
documented, provided the inmate has been in continuous custody.
A complete physical examination will be required for inmates who are out of BOP custody for
more than 30 days (e.g., furlough, writ, or a halfway house failure).
For an inmate transferred from another Bureau institution, staff need not conduct a second
complete initial physical assessment if the inmate does not present any new medical problems
and has already had a complete health assessment for this period of confinement.
c. Periodic Health Examinations. The Medical Director will ensure the availability of agespecific preventive health examinations (e.g., cancer screening) for the inmate population.
Information regarding these examinations will be made available through the A&O process,
posted information in the HSU, and individual patient education associated with clinical
encounters.
d. Food Handlers’ Examinations. Inmates will not be assigned to Food Service work details
until they are cleared by Health Services. If a complete history and physical examination has
been documented but is more than one year old, a brief in-person examination will be conducted
to update the inmate’s history and screen for the conditions listed below.
This encounter will be documented on the SF-600 and the date of clearance for Food Service will
be updated on SENTRY.
Annual Food Handler examinations will not be required, however, upon orientation to Food
Service, Food Service staff will provide inmates with an information sheet instructing them to
report to their detail supervisor should they display symptoms of any of the following:
■ Acute or chronic inflammatory conditions of the respiratory system.
■ Acute or chronic skin conditions.
P6031.04 6/3/2014

26

■ Acute or chronic intestinal infections (vomiting or diarrhea).
■ A communicable disease.
Note: HIV, HBV, or HCV infection or latent TB (positive PPD without active tuberculosis)
pose no risk of food borne transmission.
Inmates with HIV, HBV or HCV infection or latent TB are not precluded from working in
Food Service based on this status alone.
The primary care provider will determine the inmate’s suitability for Food Service.
Inmates will sign and date a copy of the information provided to them and this copy will be
maintained on file in the Food Services Department.
When an inmate notifies the detail supervisor of the presence of any of the above signs or
symptoms, he/she will be referred to the HSU for re-examination.
Inmates will be monitored daily for health and cleanliness by the Food Services Administrator,
or designee.
Inmates exhibiting signs of infected cuts or boils will be referred to the HSU for re-examination.
20. FEMALE HEALTH CARE
a. Requirements for Routine Physical Examinations of Female Inmates. In addition to the
elements described in Section 19 for complete physical examinations (long-term), the following
elements apply to routine physical examinations of female inmates:
■ A gynecological and obstetrical history, including sexual activity and any recent rape history.
■ Order a pregnancy test for females of childbearing age (urine or serum) and other tests as
clinically indicated.
■ Conduct a breast and pelvic examination. A female staff member will be present when a
male provider performs breast and pelvic examinations (except in emergency situations when
a female staff member is not available).
■ Annual breast examinations will be made available to inmates upon request.
■ Self-examination instructions will be given to all females at the time of the breast
examination.
■ Offer Pap smear; collect chlamydia, gonorrhea and/or other endo-cervical cultures from
vaginal and/or anal orifices when clinically indicated.

P6031.04 6/3/2014

27

The Medical Director will ensure the availability of age- specific preventive health examinations
(e.g., cervical, breast) for the female inmate population.
b. Mammography. Mammography will be used as a diagnostic tool.
■ Sentenced Status. Perform baseline mammography for sentenced females aged 50-74 years
old unless a younger female is assessed to have a high risk for developing breast cancer.
■ Pre-sentenced or Holdover Status. Perform baseline mammography for pre-sentenced or
holdover female inmates aged 50-74 years old who have been continuously housed at the
institution for 12 months. When the 12-month interval is reached, baseline mammography
should be scheduled within 30 days and completed before the end of the second year of being
continuously housed at the institution. Females younger than 50 years of age in pretrial or
holdover status for 90 days, and who have identified risk factors for breast cancer, should be
scheduled for baseline mammography.
If the inmate refuses mammographic screening, a Medical Treatment Refusal form (BP-A0358)
will be signed.
When a breast mastectomy is performed in the treatment of cancer, breast reconstruction is
considered Medically Necessary, Not Emergent (Level 2).
Chest x-rays are only required during the initial physical exam if clinically indicated.
Female inmates of child bearing age will be questioned as to the possibility of being pregnant
prior to taking any x-rays. This information will be documented on the Radiologic Consultation
Request/Report form (BP-A0622).
c. Prescription Birth Control. Upon request, inmates will be provided information pertaining
to appropriate methods for birth control. Ordinarily, the medical indication and appropriateness
of prescribing birth control medication in a correctional environment is limited to:
■ Hormonal manipulation for menstrual irregularity.
■ Hormonal replacement therapy in post-menopausal women as clinically indicated.
Prior approval of the Bureau’s Medical Director is required if a clinician believes birth control is
medically appropriate for a condition other than those noted above.
Sterilization may not be provided as a form of birth control.

P6031.04 6/3/2014

28

Intrauterine devices (IUDs), or other implanted contraceptive devices, will not be made available
to inmates. Inmates entering the Bureau with these devices in place will be advised of possible
complications associated with continued use, with documentation in the inmate health record.
These devices may be removed upon the inmate’s request.
d. Pregnancy. When pregnancy is confirmed, the inmate will be referred to a physician within
14 days for an initial examination and management of the pregnancy.
The HSA will notify the inmate’s unit manager promptly when pregnancy is confirmed. (Refer
to the Program Statement Birth Control, Pregnancy, Child Placement and Abortion.)
All pregnant inmates will be offered HIV antibody testing with documentation on the SF-600.
A prenatal vitamin should be prescribed to all pregnant inmates unless contraindicated.
e. Childbirth. Prior to an inmate giving birth, the Warden will ensure the person or agency
taking custody of the child is asked to take responsibility for all medical expenses from the time
of delivery (including the first three days after birth).
Unit management, or a social worker if available, will obtain a signed statement of responsibility
from whomever receives custody of the child.
This statement of responsibility will clearly indicate the signing party accepts financial
responsibility for all medical expenses for the child.
A copy of the signed statement of responsibility will be sent to the HSA for placement in the
outside hospitalization file and another copy sent to the Controller.
Administrative discretion to pay for the immediate postnatal care of the child born to a female
inmate is authorized when no other resource can be compelled to pay. Legislation is not required
to authorize payment for the child’s immediate medical needs. It is reasonable for the Bureau to
provide for the child’s medical expenses:
■ For the first three days following routine vaginal delivery.
■ Up to seven days following delivery by Cesarean section.
The Regional Director may extend this an additional seven days for extenuating circumstances
on a case-by-case basis. Any further extension will require approval by the Medical Director.

P6031.04 6/3/2014

29

f. Pregnancy Statistic Reporting Requirements. Institutions will report the name, register
number, and expected due date of all pregnant females to the Chief of Health Information
Management, Health Services Division, Central Office, via BOPNet GroupWise.
All live births will be reported to the Chief of Health Information Management.
A follow-up report is required for all pregnancies that end in other than a live birth (i.e., abortion,
miscarriage, premature birth, stillbirth).
21. INMATE IMMUNIZATIONS
Refer to the Program Statement Infectious Disease Management.
Staff will notify inmates of the availability of immunizations through A&O and posted
information in the HSU.
Health Services staff will maintain a standard immunization record in each inmate health record.
Upon request, the Health Information Department will provide inmates with a copy of their
immunization records following their release.
22. SURGICAL SERVICES
Health Services staff will ensure that Consent for Anesthesia forms (SF-522) are completed for:
■
■
■
■

All ambulatory-type surgical procedures.
Local anesthesia for diagnostic and therapeutic purposes.
Joint injections.
Flexible endoscopy.

Consent forms are strongly recommended for laceration repair (suturing), especially on the face,
or when fascia or tendon sheaths require closure.
All institutions will have written surgical policies and procedures in accordance with Joint
Commission and safety standards.

P6031.04 6/3/2014

30

23. SURGICAL PATHOLOGY
Histology/cytology specimens removed during a surgical procedure will be sent to an approved
pathologist for examination. All specimens will be packaged in preservative as indicated by type
of specimen and local procedures. All specimens will be labeled with the following:
■
■
■
■

Inmate name.
Register number.
Date of collection.
Source of specimen.

Refer to the Program Statement Dental Services for information regarding dental pathology.
24. SERIOUS ILLNESS AND DEATH PROCEDURES
An Institution Supplement will be developed to incorporate specific information covered in the
categories listed below, including:
■ Serious Illness and Death Procedures, including who may pronounce death according to state
law, and notification of the coroner or medical examiner.
■ Inmate Advance Directives (“Living Wills”).
■ Request for consideration of reduction in sentence (“compassionate release”).
■ “Do Not Resuscitate” (DNR) Orders.
For further information refer to the Program Statement Escapes/Deaths Notifications.
When an inmate’s medical condition becomes life-threatening and death may be imminent, the
principles and procedures listed below will be followed.
The Bureau remains committed to the principle of preserving and extending life. A seriously ill
or dying inmate should be provided care consistent with this goal.
When an inmate is in a community hospital, the Bureau retains authority regarding
administrative decisions (visitors, movement of the inmate, limits on medical services the Bureau
will authorize, etc.) and the hospital retains authority for professional medical decisions (drug
regimen, laboratory tests, x-rays, treatment performance, etc.).
As long as the treatment conducted by the hospital and agreed to by the inmate or family does
not exceed the scope of medical services the Bureau provides, normally the treatment will be
permitted.
P6031.04 6/3/2014

31

In most cases, the inmate will be in a local hospital and the hospital will have procedures
complying with State law regarding the involvement of next of kin.
The hospital will be permitted to follow its established bylaws concerning seriously ill or dying
inmates, e.g. initiating DNR orders and discontinuing artificial life support.
The Bureau will be kept informed of the treatment the inmate is receiving, but medical staff of
the hospital will retain the authority for decisions concerning treatment.
a. Serious Illness. An inmate’s serious illness is of immediate concern to the inmate’s family;
the institution will notify the next of kin promptly. If approved by the Warden, the immediate
family member (next of kin) will be made aware of the medical condition and the limitations
placed on visiting.
While the Bureau will continue to control conditions under which a family member may visit,
consideration will be given to providing the maximum opportunity for visitation. (Refer to
Program Statement Inmate Visiting.)
As soon as possible, the HSU will notify the Warden and Chaplain by phone or in person of the
inmate’s condition, and the Warden, or designee, will arrange to notify the family.
Subsequently, the Warden will be notified of the illness by confirming memorandum from a
medical staff member.
The memorandum will describe the illness briefly and provide a prognosis, if possible. A copy
of the memorandum will be sent to the Chaplain. If a pretrial inmate becomes seriously ill,
requires major surgery, or dies, the Warden, or designee, will also notify the committing Court
and the U.S. Attorney’s Office. (Refer to the Program Statement Escapes/Deaths Notifications.)
When inmates are suitable candidates for early release through a Reduction in Sentence (often
called compassionate release) and the inmate and family desire such an arrangement, the
institution will expedite processing of the request. (Refer to the Program Statement
Compassionate Release; Procedures for Implementation of 18 U.S.C. §§ 3582(c)(1)(A) &
4205(g)).
If an inmate is a suitable candidate for medical furlough, refer to the Program Statement
Furloughs.

P6031.04 6/3/2014

32

In case of death, the Warden or the Warden’s representative will notify the family of the
deceased in the same manner as serious illness notification.
b. Autopsies. Inmates who expire as a result of a known terminal disease do not routinely
require an autopsy. Refer to the Program Statement Autopsies, and the Autopsy Authorization
form (BP-A0797).
Before initiating an autopsy or embalming, a determination of the inmate’s religious preference
will be made. Religions, including Judaism and Islam, forbid embalming. Additionally, there
are other religion specific requirements involving autopsies and embalming.
It is critical the institution’s religious services department head be consulted prior to final
authorization for an autopsy or embalming.
Each institution will develop procedures describing when to contact the local coroner or medical
examiner regarding such issues as:
■
■
■
■

Performing an autopsy.
Who will perform the autopsy.
Obtaining State-approved death certificates.
Local transportation of the body.

State laws regarding these issues vary greatly and when legal questions arise, the Regional
Counsel should be contacted. State law provisions and guidelines on when to contact the coroner
or medical examiner will be incorporated into an Institution Supplement and a copy forwarded to
the Regional Counsel.
c. Advance Directives and “Do Not Resuscitate (DNR) Orders.” Increasingly, inmate and
health care providers are confronted with difficult and sensitive decisions regarding health care,
including the decision to have extraordinary means of care and life support withheld or
withdrawn in cases of a terminal condition or irreversible illness. This section provides guidance
on creating and implementing these advance directives.
Inmates may direct, in advance, to withhold or withdraw certain medical treatments when
recovery or cure is not possible.
Inmates may appoint, in advance, proxy decision makers who will make critical health care
decisions for them should they become incapacitated and unable to make such decisions for
themselves.

P6031.04 6/3/2014

33

The Bureau’s withholding or withdrawal of resuscitative or life-support services pursuant to an
Advance Directive or DNR order, is consistent with sound medical practice and is not associated
with assisting suicide, voluntary euthanasia, or expediting the inmate’s death.
The patient’s right to refuse medical treatment is not absolute and, in all cases, will be weighed
against legitimate governmental interests, including the security and orderly operation of
correctional institutions.
d. Institution Supplement. To facilitate the creation and implementation of advance directives
and DNR orders, each institution will develop an Institution Supplement according to this
Program Statement.
The Warden, Regional Director, and Medical Director must review and approve Institution
Supplements. Supplements will be negotiated locally prior to implementation.
Regional and local Bureau legal staff should be consulted in drafting Institution Supplements
under this section.
(1) Advance Directives. Each Institution Supplement addressing advance directives must:
■ Provide information which complies with the law of the state where the institution is located.
A copy of the relevant state’s law should be an attachment to each Institution Supplement.
■ Include a sample standard form for inmate use if available from the relevant state statutes on
advance directives.
■ Include instructions for inmates wishing to execute advance directives before, or after, the
onset of a seriously debilitating or terminal illness, including the option of retaining private
legal counsel at the inmate’s expense for assistance.
■ Require filing inmates’ executed advance directives in the inmate health record.
(2) DNR Orders. Each Institution Supplement addressing DNR orders must:
■ Provide information which complies with the law of the state where the institution is located.
A copy of the relevant state’s statutes should be an attachment to the Institution Supplement,
if they exist. This includes state laws addressing non-liability of healthcare practitioners who
implement advance directives in good faith.
■ Instruct that, in all cases, decisions a competent inmate expressed supersede any previously
executed advance directive to the contrary.
■ State that DNR orders will never be invoked while an inmate is housed at a general
population institution. Emergency resuscitative measures must always be performed on an
inmate who suffers cardiopulmonary arrest at a general population institution. Advance
P6031.04 6/3/2014

34

directives may be implemented only at community health care facilities or MRCs, while the
inmate is under a physician’s direct care and treatment.
■ Instruct that validly executed advance directives will be honored by entering DNR orders as
appropriate at MRCs.
■ Instruct that validly executed advance directives will be honored by community healthcare
facilities according to their by-laws and relevant state and local laws.
The Institution Supplement will also include the following procedures for implementing DNRs:
(a) All DNR orders written for inmates in MRCs must be approved by the Clinical Director
(CD) or acting CD.
(b) A valid DNR order must be documented in the inmate’s health record, including:
■ Standard terminology (i.e., “Do Not Resuscitate” or “DNR”), legibly written, signed by the
ordering physician, and placed on the front of the record and inpatient chart, as well as the
doctor’s order sheet.
■ The inmate’s diagnosis.
■ The inmate’s prognosis.
■ The inmate’s written advance directive, or other authorized expression of healthcare
decisions, as well as available documentation of the inmate’s informed consent, when
available.
■ Documentation regarding the inmate’s competence, when the decision to enter a DNR is
based on his/her expressed request.
■ The wishes of immediate family member(s), if available.
■ Decisions and recommendations of other medical staff or consultants, with documentation of
names.
(c) DNR orders are subject to regular review by the ordering physician.
(d) Inmates with DNRs in their health record remain entitled to maximal therapeutic efforts
short of resuscitation.
(e) Bureau physicians at MRCs may not be compelled to sign a DNR based on their clinical
judgments, or ethical or religious convictions.
To protect the interests of both the inmate and the Government, the Government may, in some
cases, seek judicial or administrative review of the declaration in an Advance Directive.

P6031.04 6/3/2014

35

When the inmate is unconscious or otherwise unable or incompetent to participate in the
decision, every reasonable effort will be undertaken to obtain written concurrence of one or
several immediate family members. The attending physician must document these efforts in the
health record.
A DNR order may be the result of the attending physician’s decision that the inmate is in a
terminal condition and further medical treatment is futile. When a DNR order conflict exists
between the primary care physician and the inmate or the inmate’s proxy decision maker, a
referral to the MRC ethics committee will be made.
Should the committee be unable to resolve the conflict, the issue will be referred to the Bureau’s
Medical Director for final determination.
25. BODY SEARCHES FOR CONTRABAND
Under no circumstances will laxatives, enemas, or emetics (any form) be used to induce a bowel
movement or vomiting to help remove contraband. The only exception is, if a medical condition
requires prescribing laxatives, enemas, or emetics, the Clinical Director must order this
medication weighing the potential danger to the inmate if contraband is present.
When a Warden authorizes a cavity search as stated in the Program Statement Searches of
Housing Units, Inmates, and Inmate Work Areas, qualified health care personnel will
perform the cavity search.
The use of a fluoroscope, major instrument (including anoscope or vaginal speculum), urinary
catheter, or surgical intrusion will only be authorized for medical reasons, with the inmate’s
consent.
The only exception is if an x-ray examination is determined necessary for the safety and security
of the institution, the Warden, with the Regional Director’s approval, may authorize the
physician to order a non-repetitive x-ray examination to determine if concealed contraband is
present in or on the inmate. (Refer to the Program Statement Searches of Housing Units,
Inmates, and Inmate Work Areas for further direction.)
26. SPECIAL DIETS
Unless clinically indicated as part of the treatment regimen, medical staff will not order special
food items. When a special diet is required to supplement a medical regimen, the Program
Statement Food Service Manual will be consulted.

P6031.04 6/3/2014

36

Special diets will be prescribed only by the CD, staff physician, staff psychiatrist, or staff dentist.
MLPs at MRCs may prescribe a special diet, but it must be countersigned by the primary
physician.
Weight loss diet programs will not be implemented without the physician’s approval.
Documenting patient education regarding diet recommendations in the health record is the
responsibility of the prescriber and dietitian.
If there is no full-time dietitian, it is highly recommended that MRCs contract for a consultant
dietitian who will provide counseling services and patient education.
27. EYE CARE
a. Eyeglasses. The Bureau will furnish prescription eyeglasses to any inmate requiring them, as
documented through a professional prescription. Federal Prison Industries, FCI Butner, NC, is
the only approved vendor at Government expense.
Inmates may purchase reading glasses at commissaries which stock them.
The HSA, in consultation with the CD and consultant optometrist, may elect to stock a supply of
reading glasses in various magnifications which the optometrist may dispense when the inmate
only requires magnification.
The HSA may purchase glasses through usual supply procedures.
Inmates may retain their eyeglasses at admission. All such glasses are subject to inspection for
contraband. Inmates may retain this pair of eyeglasses until the lenses or frames must be
changed or repaired, at which point the Bureau will furnish replacement eyeglasses through
Federal Prison Industries.
b. Contact Lenses. Contact lenses will only be prescribed when, in the clinical judgment of a
Bureau or contract optometrist or ophthalmologist, with the concurrence of the CD and HSA, an
eye-refractive error is best treated with the prescription of contact lenses. Generally these cases
are limited to the following:
■ Diagnosis of keratoconus.
■ Certain inmates with artificial lens implants.
P6031.04 6/3/2014

37

HSU staff will evaluate sentenced inmates arriving at an institution with contact lenses and refer
them to a Bureau or contract optometrist or ophthalmologist to determine whether they may
retain the lenses. Unless contact lenses are medically necessary, HSU staff will inform the
inmate that an appointment will be made with the institution’s optometrist for an eyeglass
prescription.
The only exception to the above is non-sentenced inmates who are housed in BOP institutions.
Once the glasses are received, the contact lenses must be returned to the inmate’s personal
property or mailed home.
HSAs will ensure adequate contact lens supplies are available for inmates authorized contact
lenses (those who must wear contacts as opposed to glasses), non-sentenced inmates, or those
awaiting eyeglasses.
28. HEARING CONSERVATION PROGRAM
Whenever individual occupational noise exposure equals or exceeds the eight-hour time
weighted average (TWA) sound level of 85 decibels (and above) measured on the “A” scale
(dBA), the institution will initiate a hearing conservation program. At a minimum, the program
will meet the requirements of paragraphs (c) through (o) of 29 CFR Part 1910.95. Major
elements include:
■ Monitoring areas where noise levels are expected to equal or exceed an eight hour time
weighted average of 85 dBA.
■ Notification of inmates occupationally exposed to a TWA at or above 85 dBA.
■ Audiometric testing for those exposed.
■ A training program.
a. Initial Survey. The Safety Manager will arrange for an initial survey of the institution to
identify work areas where inmates are subjected to noise exposure of 85 dBA TWA or higher.
The Safety Manager will designate any work assignment where an inmate is exposed to a TWA
threshold that meets or exceeds 85 dBA as a high noise job.
The Safety Manager will notify the HSA and the affected department head of each high-noise
job designation. Each inmate assigned to a high-noise job will:
■ Be fitted with hearing protection.
■ Be required to wear the hearing protection device while working.
P6031.04 6/3/2014

38

■ Be trained in accordance with 29 CFR 1910.95.
The Safety Manager will be responsible for ensuring hearing protection fitting and training. The
department head of the high noise area is responsible for ensuring that hearing protection is worn
in the work area.
The department head will notify the HSA when an inmate is assigned to a high-noise area. The
HSA or designee, will obtain a baseline audiometric test as soon as possible, but no later than six
months after that job assignment, and the HSA will notify the department head of the date when
testing is performed. Audiometric tests will be made at the 500, 1,000, 2,000, 3,000,
4,000, 6,000, and 8,000 Hertz (hz) frequencies.
When mobile test vans are used to meet the audiometric testing obligation, the HSA will obtain
the audiometric test as soon as possible, but no later than one year after the job assignment.
Detectable hearing loss at initial testing does not preclude the inmate’s assignment to a highnoise area, provided hearing protection is worn.
Inmates who are deaf may be allowed to work in high- noise areas, provided an assessment of
safety factors is performed to determine if the work place is otherwise safe and appropriate, with
or without reasonable accommodations.
Inmates who are intra-system transfers, and who are assigned to a high-noise area in their new
institution, will use the baseline audiogram performed at the sending institution, if available.
b. Annual Retesting. Each inmate assigned to a high-noise area must receive audiometric
retesting at least annually. It is the department head’s responsibility to notify the HSA of each
inmate needing annual testing.
Upon retesting, any inmate found to have a standard threshold change or shift of 10 dB or more
as compared to a baseline average over 2,000, 3,000, or 4,000 hz frequencies must be retested
within 30 days.
The results of the retest will be considered the annual audiometric test.
It is important to factor in age-related hearing loss as described in 29 CFR 1910.95, Appendix F,
when administering an annual retest.

P6031.04 6/3/2014

39

Unless the Clinical Director determines that a standard threshold shift of greater than 10 dB is
not work-related or aggravated by occupational noise exposure, the Safety Manager will ensure
that the inmate is:
■ Refitted with hearing protection.
■ Trained in its use and care.
■ Required to wear the hearing protective device.
The HSA will notify the Safety Manager of each inmate who must be refitted and retrained.
c. Audiometric Testing. Audiometric tests will be performed by a licensed or certified
audiologist, otolaryngologist, or other physician, or by a technician who is certified by the
Council of Accreditation in Occupational Hearing Conservation. Staff who have demonstrated
skill and knowledge satisfactorily, as determined by a licensed or certified audiologist,
otolaryngologist, or other physician, may also perform audiometric testing.
Skill and knowledge must be demonstrated in:
■ Administering audiometric examinations.
■ Obtaining valid audiograms.
■ Properly using, maintaining, and checking calibration and proper functioning of the
audiometers being used.
A technician who operates microprocessor audiometers does not need to be certified. A
technician who performs audiometric tests must be responsible to an audiologist,
otolaryngologist, or physician.
Audiometric tests will be conducted with audiometers that meet the specifications of the
American National Standard Specification for Audiometers, S3.6-1969.
If used, pulse-toned and self-recording audiometers will meet the requirements specified in 29
CFR 1910.95, Appendix C, “Audiometric Measuring Instruments.”
Audiometric calibrations will be performed in accordance with 29 CFR 1910.95 (h)(5).
Record keeping will be performed and maintained in accordance with 29 CFR 1910.95 (m).

P6031.04 6/3/2014

40

29. DEAFNESS AND HEARING AIDS
Hearing aids can be justified only by bona fide clinical indication. The CD, in consultation with
an audiologist or otolaryngologist, will determine if a hearing aid is medically necessary.
HSAs will ensure that batteries are available for inmates with hearing aids.
If an inmate brings a personal hearing aid into the institution, after verification, he/she will be
allowed to keep it. However, the inmate may not purchase a personal hearing aid once
committed to an institution.
30. INMATES WITH GENDER IDENTITY DISORDER
Inmates with a possible diagnosis of Gender Identity Disorder (GID), including inmates who
assert they have GID, will receive thorough medical and mental health evaluations from medical
professionals with basic competence in the assessment of the DSM-IV/ICD-10 sexual disorders
and who have participated in BOP’s GID training, including the review of all available
community health records. The evaluation will include an assessment of the inmate’s treatment
and life experiences prior to incarceration as well as experiences during incarceration (including
hormone therapy, completed or in-process surgical interventions, real life experience consistent
with the inmate’s gender identity, private expressions that conform to the preferred gender, and
counseling).
If a diagnosis of GID is reached, a proposed treatment plan will be developed which promotes
the physical and mental stability of the patient. The development of the treatment plan is not
solely dependent on services provided or the inmate’s life experiences prior to incarceration.
The treatment plan may include elements or services that were, or were not, provided prior to
incarceration, including, but not limited to: those elements of the real life experience consistent
with the prison environment, hormone therapy, and counseling. Treatment plans will be
reviewed regularly and updated as necessary.
Current, accepted standards of care will be used as a reference for developing the treatment plan.
All appropriate treatment options prescribed for inmates with GID in currently accepted
standards of care will be taken into consideration during evaluation by the appropriate medical
and mental health care staff. Each treatment plan or denial of treatment must be reviewed by the
Medical Director or BOP Chief Psychiatrist. Hormone therapy must be requested through the
non-formulary review process, and approved by the Medical Director and /or Chief Psychiatrist.
Consultation with the Chief of Psychology prior to such approval may be appropriate in some
cases.

P6031.04 6/3/2014

41

In summary, inmates in the custody of the Bureau with a possible diagnosis of GID will receive a
current individualized assessment and evaluation. Treatment options will not be precluded
solely due to level of services received, or lack of services, prior to incarceration.
31. STERILIZATION
Inmates will not be sterilized, except for bona fide medical indications (e.g. as the result of
surgical treatment for cancer of the reproductive organs).
32. DIALYSIS
Inmates with renal disease requiring dialysis (including peritoneal dialysis) will be referred to the
Medical Designator for transfer to an MRC or other institution capable of providing dialysis.
A dialysis “re-use” program is permitted.
33. SEXUALLY TRANSMITTED DISEASES
Refer to the Program Statement Infectious Disease Management.
34. STANDARD PROCEDURES FOR DETERMINING ALCOHOL INTOXICATION
Staff may be asked to determine whether an inmate is intoxicated. Two procedures are used most
often to determine alcohol intoxication.
The Captain, or designee, may administer a breathalyzer test to determine the presence of
alcohol. Use of a breathalyzer will remain a non-medical function.
Medical staff may be asked to obtain a blood sample to determine alcohol content.
Usually, blood alcohol testing would be reserved for situations when this information is needed
as part of a criminal investigation, or when specifically requested by the Warden. Then, medical
staff will:
■ Draw blood and forward it to an approved laboratory for testing.
■ Complete all chain-of-custody documentation in accordance with the request for this
examination.

P6031.04 6/3/2014

42

The inmate’s consent is required before blood is drawn, except in medical emergencies when the
patient is unable to consent.
35. DETOXIFICATION
The CD will establish local protocols for evaluating and treating inmates who require
detoxification from mood and mind altering substances such as alcohol, opiates, hypnotics,
sedatives, etc. Based on specific guidance from the Medical Director, these detoxification
protocols will be implemented based on a physician’s order.
Treatment and supportive measures will permit withdrawal with minimal physiological
discomfort.
Methadone Detoxification. MCCs, MDCs, FDCs, MRCs, the FTC, and jail units with a
methadone detoxification mission, will provide methadone detoxification if clinically indicated.
These missions will be determined by the Medical Director.
These institutions must have a current methadone license.
This program requires special registration through the Substance Abuse and Mental Health
Services Administration (SAMHSA)
If an institution has a methadone detoxification program, the institution Chief Pharmacist will
complete and maintain registration for a methadone program.
Waivers to this requirement must be requested in writing to the Medical Director. The request
must detail a specific plan with a community-based program which can readily provide
methadone detoxification.
Institutions which could conceivably house pregnant inmates must have a contingency in place
for methadone maintenance. Ordinarily, pregnant inmates should not be detoxified from
opiates until after delivery.
Refer to the Program Statement Pharmacy Services for additional information regarding
methadone administration.

P6031.04 6/3/2014

43

36. VITAMINS AND NUTRITIONAL SUPPLEMENTS
Inmates will be referred to the commissary to purchase vitamins when their use is for general
prevention or health maintenance or for conditions when their use has been promoted but not
scientifically proven (e.g. Peyronie’s disease, macular degeneration.)
Each multiple vitamin tablet may not contain more than 150% of the Recommended Daily
Allowance (RDA) of each vitamin and mineral.
Particular attention should be given to limiting excessive intake of the fat-soluble vitamins (A, D,
E, and K.)
Vitamin C tablets may not exceed 500 mg per tablet.
Vitamins which may be purchased from the commissary are listed in the Program Statement
Trust Fund/Deposit Fund Manual.
When a vitamin supplement is clinically indicated as part of a treatment regimen, the vitamin
will be considered medication and will be supplied by the HSU, subject to restrictions in the
National Drug Formulary.
Health Services staff will not prescribe, nor will the commissary sell, nutritional supplements
such as glucosamine/chondroitin, fish oil, herbal preparations, and other non-Food and Drug
Administration (FDA) approved substances.
37. AUTOLOGOUS BLOOD BANKING
The CD will determine when autologous blood collection is medically necessary (e.g. the inmate
has an extremely rare blood type, surgery will predictably require transfusion, such that
autologous blood banking may be performed).
The CD may authorize autologous blood collection.
Surgical consultants may not require the Bureau to authorize autologous blood banking for an
inmate prior to surgery.
38. ORGAN DONATION BY INMATES
These procedures apply to inmates currently incarcerated in the Bureau, not to posthumous
donations:
P6031.04 6/3/2014

44

Organ donation is only permitted when the recipient is a member of the inmate donor’s
immediate family (parents, siblings, and biological children.)
Hospitalizations or fees involved will not be at the Government’s expense including all costs
associated with guarding the inmate at off-site facilities. This includes the U.S. Marshals
Service.
The inmate must sign a statement indicating the desire to donate an organ to a specific relative.
The consent must state the following:
■ The inmate understands the possible dangers of the operation.
■ The inmate agrees of his/her own free will.
■ The Government will not be held responsible for any complications or financial
responsibilities.
When an inmate is appropriately designated as community custody, the inmate may request
consideration for a medical furlough, in accordance with the Program Statement on Inmate
Furloughs.
The local institution will coordinate procedures such as transportation, custody, classification,
compatibility determinations, evaluation, hospitalization, furlough status, etc.
Inmates are not authorized to donate blood or blood products.
Inmates may not list themselves as posthumous organ donors while incarcerated.
Any exception to the above will be considered by the Medical Director on a case by case basis.
39. INMATES AS RECIPIENTS OF ORGAN TRANSPLANTATION
The Bureau will consider organ transplantation as a treatment option for inmates in accordance
with the following procedures:
When the CD at an institution determines it is medically necessary to evaluate an inmate’s
suitability for an organ transplant, he or she will initiate an organ transplant laboratory/ specialist
consultant work-up at the institution.

P6031.04 6/3/2014

45

When a specialist determines an inmate may be a potential candidate for organ transplantation
and the Clinical Director recommends that further evaluation is medically appropriate; the
inmate will be evaluated at an appropriate facility such as a transplant center in the vicinity of
either the institution or a Bureau MRC.
If an organ transplant center considers an inmate suitable for a transplant, the institution CD will
compile all pertinent medical/surgical/case management/mental health/social work information
and forward to the Medical Director for consideration.
If the Medical Director determines that an organ transplant is medically indicated, the inmate
will be approved for surgery at an appropriate transplant center in accordance with Bureau
policy, transplant center regulations, and state and federal laws.
The Bureau will pay medical care and hospitalization costs associated with organ donors.
These expenses are limited specifically to those costs directly related to the transplant procedure
itself.
40. PHYSICAL THERAPY/REHABILITATION SERVICES
Bureau-staffed Rehabilitation Services are ordinarily limited to medically designated inmates at
MRCs. Each MRC will have a written local policy outlining at least the following topics:
■
■
■
■
■
■
■
■
■

Scope of services.
Referral process from health care providers.
Referral process to health care providers.
Use of inmate workers in the department.
Quality Improvement Program.
Preventive maintenance of equipment.
Infection control.
Procurement of durable medical equipment and supplies.
Safety/security.

Inmates at non-MRCs occasionally require assessment and treatment by a physical therapist.
CDs should consider telephone or tele-health consultation with an MRC therapist to help design
a specific program for a specific inmate. Alternatively, therapists in the local community may be
used intermittently.
Inmates requiring extended, formal physical therapy should be referred to an MRC via a Medical
/Surgical and Psychiatric Referral Request form (BP-A0770).
P6031.04 6/3/2014

46

Prior to submitting the BP-A0770, the CD will discuss the inmate’s diagnosis and current
condition with an MRC therapist, to determine if the transfer is appropriate, and if the inmate can
or will benefit from physical therapy or other modalities.
41. SOCIAL WORK SERVICES
Currently, Social Work services are available only at MRCs. Guidance from the Medical
Director will be provided in relation to expanding the role of social workers to serve non-MRC
inmates.
Each MRC will have a written local policy for Social Work Services, outlining the following
topics:
■
■
■
■
■

Scope of services.
Referral process from health care providers.
Referral process to health care providers.
Quality Improvement Program.
Transitional care/release planning, end-of-life care, and advance directives.

42. SEXUAL ASSAULT PREVENTION AND INTERVENTION
a. Prevention. General training requirements for staff will be in accordance with the Program
Statement Sexually Abusive Behavior Prevention and Intervention Program.
Medical staff will refer to Psychology Services all inmates who have been identified as victims
of:
■
■
■
■

Sexually aggressive behavior.
Sexual pressure.
Sexual harassment.
Sexual assault.

b. Intervention. When an inmate reports being sexually assaulted, medical staff will document
the inmate’s complaint and subjective/objective findings fully on the Inmate Injury Assessment
and Followup form (BP-A0362) and notify institution authorities regarding this complaint
immediately. The plan for further evaluation and treatment will also be included on the BPA0362.

P6031.04 6/3/2014

47

In order not to compromise medical evidence on an inmate who reports a recent sexual assault, it
is recommended that the inmate be transported to a community facility/rape crisis center that is
equipped (in accordance with local laws) to evaluate and treat sexual assault victims. (Refer to
the Program Statement Sexually Abusive Behavior Prevention and Intervention Program.)
Institutions may use on-call contracted clinical care staff to provide sexual abuse/assault
treatment. These clinical care providers would report to the institution via a contractual
arrangement when institution authorities call.
Only in institutions where extreme security concerns exist may in-house physicians be used to
provide treatment, examination, and forensic evidence gathering to inmates who report sexual
abuse/assault.
Annually, these staff must be specifically trained and demonstrate knowledge and skills in sexual
abuse/ assault treatment and forensic evidence gathering.
An individual who has recognized expertise in this field (e.g. sexual abuse/assault treatment staff
in a community-based hospital emergency department or community-based rape crisis center)
must perform this training.
The Clinical Director will ensure (whether treatment has been provided in-house or in the
community) that appropriate infectious disease testing, medical examination, and medical
physical evidence collection has been conducted and the results of all examinations/ evaluations
have been provided to institution SIS staff.
Specific procedures for evaluating and treating victims of sexual abuse/assault will be included
in the Institution Supplement for the Sexually Abusive Behavior Prevention and Intervention
Program.
43. EXAMINATION BY PERSONAL PHYSICIAN
Ordinarily, inmates are not permitted to use their own physicians or other providers, whether on
a reimbursable or non-reimbursable basis, or whether there was a prior relationship between the
inmate and the provider.
There is no prohibition if a provider, ordinarily used or specially engaged by the Bureau,
happens to have been a prior health care provider to the inmate; however, this is discouraged.

P6031.04 6/3/2014

48

Discretion may be exercised to permit a private physician visit only when a private physician
was treating an inmate prior to incarceration. Should an inmate request to be examined by a
specific physician during incarceration, the Warden, upon consultation with the Regional
Director and Medical Director, may permit such a visit for examination only at the inmate’s
expense.
Such action may not be routine and it is anticipated that it will be infrequent.
Should permission be granted for such a visit, the Warden will ensure reasonable time and space
for the examination are provided.
The inmate will execute an Authorization for Release of Medical Information (BP-A0621).
The visiting physician will be licensed by the state in which the institution is located. The Health
Services Administrator, or designee, will verify the license in accordance with the Program
Statement Credentialing, Privileging, and Practice Agreements.
The staff physician will meet with the visiting physician and freely discuss the case and be
present during the exam.
The staff physician will have authority from the Warden to terminate the examination if
inappropriate activities are witnessed.
While the visiting physician will not be provided the inmate's health record for unsupervised
perusal (but may review it under supervision), the staff physician should freely discuss the
record, particularly in response to the visiting physician's questions.
If the personal physician requests copies of the inmate’s health record, this request will be
managed in accordance with the Freedom of Information Act (FOIA) as described in Program
Statement on Health Information Management.
The visiting physician will provide a written report. The staff physician should review any
recommendations the visiting physician makes and accept any documents that the physician may
present, but is under no obligation to carry out the visitor's recommendations.
If the private physician’s recommendations are not followed, an entry will be made in the
inmate’s health record to explain this decision.
Any documents the visiting physician provided will be filed properly in the health record.
(Section 5, Civilian Records Divider)

P6031.04 6/3/2014

49

The staff physician will document the visit in the progress notes.
44. INVOLUNTARY MEDICAL TREATMENT/REFUSAL OF TREATMENT BY
INMATES
See the Program Statement Psychiatric Services for guidance regarding involuntary medication
and/or hospitalization for psychiatric illness.
Any refusal of recommended or offered treatment or a diagnostic procedure will be documented
in the inmate health record. The inmate will be asked to sign a Medical Treatment Refusal form
(BP-A0358).
If the inmate refuses to sign, two staff witnesses will attest and sign to the fact that the
consequences of refusing the proposed treatment or procedure were explained to the inmate in a
language he/she understood.
As a general rule, medical and dental treatment including medication is given only when the
inmate consents. Exceptions may be made when a Bureau or contract physician determines:
■ There is a danger to life or of serious permanent injury to the inmate.
■ The inmate poses a risk to others by refusing treatment (e.g. infectious tuberculosis).
■ There is a court order for evaluation or treatment to be provided.
Diagnostic procedures relating to potential communicable disease may be mandatory for the
protection of the inmate or other inmates and staff. (Refer to the Program Statement Infectious
Disease Management.) These procedures include, but are not limited to:
■ Tuberculin screening tests.
■ Chest x-rays.
■ Blood specimens for hepatitis or HIV (post-exposure incident).
Refusal of such procedures will require an incident report. The Clinical Director will determine
whether medical isolation is clinically indicated.
An inmate may revoke a signed BP-A0358 if he/she later decides to follow the health care
providers’ medical advice. If the proposed treatment’s potential outcome has been compromised
by the delay associated with the inmate’s refusal, this will be communicated to the inmate and

P6031.04 6/3/2014

50

documented thoroughly in the inmate’s health record (e.g., delay in accepting recommended
treatment for cancer may affect the treatment’s success.)
The CD and/or HSA should consult with Bureau legal staff whenever questions arise regarding
involuntary medical treatment not addressed in this Program Statement.
45. EXPERIMENTATION AND PHARMACEUTICAL TESTING
Inmates in the custody of the Federal Bureau of Prisons will not be used as subjects for any nontherapeutic medical experimentation.
This does not preclude the use of approved clinical trials that may be warranted for a specific
inmate’s diagnosis or treatment when recommended by the CD and approved by the Medical
Director.
Such measures must have the inmate’s prior written consent and must be conducted under
conditions approved by the Department of Health and Human Services.
Research regarding disease prevalence, response to accepted therapeutic interventions, etc., can
be performed under protocols meeting the requirements of the Program Statement Research.
46. RADIOLOGY SERVICES
Radiology services provided or made available by the Bureau will be designed to meet the needs
of patients in accordance with professional practices and legal requirements. Appropriate
radiographic or fluoroscopic diagnostic and treatment services will be provided or made
available.
a. Staffing. A registered radiologic technologist or a radiologic technician is required as part of
each institution's clinical staff. Bureau staff with documentation of radiologic technician training
obtained from an accredited community source may also be utilized.
The registered radiologic technologist will be a graduate of a program in radiologic technology,
approved by the Council on Medical Education of the American Medical Association.
b. Procedure Manual. Each institution will have written procedures which cover:
■ Identification of the current director of radiology.
■ Scheduling.
■ Examinations performed.
P6031.04 6/3/2014

51

■
■
■
■
■
■
■
■
■
■
■
■
■
■

Administration of diagnostic materials.
Infection control procedures.
Management of isolation patients.
Management of emergency patients.
Care of the critically ill.
Preventive maintenance.
Radiation safety/safety precautions.
Disaster plans.
Required records and reports.
Preparation of patients.
Calibration and safe use of equipment.
Inspection of x-ray safety equipment for defects.
Radiation exposure precautions.
Precious metal recovery.

c. Record keeping. A daily x-ray log, in a bound ledger or in electronic form, will be
established in the x-ray department. The log will contain:
■
■
■
■
■
■
■
■
■
■

Register number.
Patient name.
Type of study.
Number of exposures.
Name of person performing study.
X-ray exposure technique.
Reason for and number of retakes, if applicable.
Date film was sent for interpretation.
Date report returned.
Date film was returned.

X-ray films will be identified with a name imprint system. Imprint identification of radiographic
films is the only method permitted. Information required includes:
■
■
■
■
■
■

Institution name.
Patient name.
Register number.
Date of birth.
Sex.
Date of exam.

P6031.04 6/3/2014

52

d. Privacy. A concerted effort will be made to ensure patient privacy at all times, particularly
for undressing and dressing, examination, waiting in the department, and evacuation of contrast
media.
The changing area and patient bathroom will connect directly with the examination room when
physical plant and resources permit.
e. Ordering Radiographic Examinations. Diagnostic radiology services will be performed
only upon the written request of a physician, dentist, or MLP.
A Radiographic Report (SF-519A) will be used for ordering radiographic exams. (Forms other
than the standard form may be used, if they are the designated form of a contractual, non-Bureau
radiology service.) All forms must contain:
■
■
■
■
■
■
■
■

Patient’s full name and register number.
Age and sex.
Examination requested.
Name of requesting provider.
Reason for the examination.
Inpatient or outpatient status (if applicable).
Date of requested examination.
Name of the institution.

f. Radioactive Sources/Radioisotopes. Use of any radioactive sources or radioisotopes (MRCs
only) will be limited to physicians who have been granted privileges for radioactive sources.
Orders for using radioactive sources or radioisotopes will be written and accompanied by:
■
■
■
■

A concise statement of reason for use.
Total dosage.
Incremental dosages in standard measurements (cGy or Rads).
Number of treatments.

g. Evaluation/Interpretation of Radiographic Film. After the examination is completed, the
date of the exam will be written on the request form.
The ordering clinician will review all STAT requests on the same date as ordered.

P6031.04 6/3/2014

53

Ideally, films should be reviewed (a “wet read”) prior to sending the films to a radiologist for
interpretation to look for abnormalities such as active TB or fractures which require immediate
attention.
This review should be performed within two working days of the examination, so as not to delay
the final interpretation.
Films will then be sent for a radiologist’s interpretation.
A radiologist will interpret all x-ray examinations; the interpretations will be recorded on the xray report form, or on a report form the radiology group uses.
The radiologist who interpreted the film must sign (authenticate) all completed x-ray reports.
h. Distribution of Reports. Authenticated, dated reports of all examinations performed will be
filed in the inmate’s health record.
Completed radiographic reports will be reviewed within two working days, dated, and initialed
by the CD prior to distribution and filing.
The reviewing physician must ensure that timely, appropriate follow-up actions are initiated on
all abnormal findings, and that any actions taken are documented in the Progress Notes of the
inmate’s health record.
The original copy of the completed report will be filed in the inmate’s health record.
The second copy will be distributed to the requesting clinician.
The third copy will be filed in the inmate’s x-ray film envelope.
i. Filing/Transfer/Retention of Radiographic Files. Radiographic films on inmates will be
filed in the terminal digit format, the same format as for inmate health records.
Each film envelope will contain the inmate’s name and register number, with a chronological
record of the dates and studies performed.

P6031.04 6/3/2014

54

Radiographic films of inmates being transferred to other Federal institutions will be mailed to the
receiving institution within five working days of when the inmate is transferred. All available xrays will accompany the inmate’s health record at the time of transfer to an MRC.
Files on inmates released from Federal custody will be placed in an inactive file. The terminal
digit system will be used on inactive files, and they will be separated by year.
Inactive files will be maintained in a separate secure area and kept for five years. During the
sixth year, they will be transferred to the Defense Logistics Agency for silver recovery and
destruction.
j. Safety. Signs will be posted on the door to the X-ray Suite and prominently inside the
department, instructing individuals to notify the technician if they are pregnant.
When diagnostic agents are administered, safety precautions will include provision for an
emergency drug tray, oxygen, airways, and the capability to administer intravenous support.
Appropriate safety equipment will be used for all examinations. Leaded gloves, aprons, and
gonadal shields will be visually inspected by staff and films of the shields will be taken at
least twice a year for defects.
The films will be sent to the radiologist for interpretation.
Documentation must include a signed report from the radiologist.
Fluoroscopy may also be used to inspect x-ray safety equipment, with signed documentation by a
radiologist.
Precautions will be taken to minimize radiation exposure through appropriate shielding and
collimation. All doors must be closed during x-ray procedures. The field will be coned down
with a collimator as much as possible.
Exposure switches of equipment must be arranged to prevent its operation from outside the
shielded area.
The person performing portable x-ray procedures, as well as anyone assisting, will wear a lead
apron. Lead gloves will be provided if manual support of position for x-ray is necessary.

P6031.04 6/3/2014

55

All unnecessary personnel will be removed from the immediate area, and the technician
performing the procedure will stand as far away as possible from the x-ray tube when making an
exposure.
Proper shielding of radiation sources will be maintained. Periodic inspection and evaluation of
radiation sources, including calibration of equipment, will comply with Federal, state, and local
laws and regulations.
OSHA and FDA regulations regarding the handling, removal, and storage of any radioactive
material will be followed.
k. Radiation Monitoring. All personnel who use or work in close proximity to radiological
equipment will wear a film badge while on duty to monitor cumulative radiation exposure.
Individuals will ensure that their badges are not subjected to unnecessary exposure or left in the
x-ray room.
Quarterly reports of cumulative exposure will be maintained by the HSA and reviewed and
initialed by the CD.
All reports of high exposure or overexposure will be investigated to determine the cause.
FDA recommendations will be followed.
l. FDA Radiation Survey. The FDA requires surveys of radiographic equipment at HSUs
every two years. The HSA, in consultation with the RHSA, will take corrective action and
prepare a response to the report. The HSA will maintain a copy of the report and the corrective
action taken if appropriate.
m. Use of X-ray for Body Searches. This requires an order from the Warden with the Regional
Director’s approval. Refer to the Program Statement Searches of Housing Units, Inmates, and
Inmate Work Areas.
n. Preventive Maintenance. All HSUs will establish a preventive maintenance program to be
conducted by qualified staff (i.e., a certified biomedical staff member) or establish service
contracts for repair and preventive maintenance of radiographic equipment.
Manufacturer’s recommendations will be followed when establishing preventive maintenance
procedures.

P6031.04 6/3/2014

56

Infection control procedures will be followed after each inmate contact with a cassette. This
entails wiping the cassette with an approved cleaning solution (check manufacturer's
recommendations).
The x-ray table top must be wiped down with a disinfectant solution after each patient use.
o. Precious Metal Recovery Program. It is DOJ policy that, unless exempted by the Assistant
Attorney General for Administration or designee, a silver recovery program will be implemented
at each Bureau location using precious metal-bearing waste.
Each institution is required to comply with the support agreement between the Department of
Defense (DOD) and DOJ Number SC 4400-88154-804, May 1986, and the Program Statement
Property Management Manual.
Written procedures will be established at each institution to recover precious metals from scrap
and waste film. Examples of precious metal-bearing waste include photographic fixing (hypo)
solution, photographic and x-ray film, silver alloys, dental scrap, batteries, and electronic parts.
Scrap film is film damaged in processing or purged from the medical files; it will be kept until
sufficient quantities are available to warrant silver recovery.
Institutions with automatic film processors will have silver recovery units attached to the
processor.
Institutions using a manual, tank-type processing system will save all hypo solution.
47. MISCELLANEOUS
a. Medical Duty Restrictions/Convalescence. Medical Duty Status restrictions must be
consistent with the inmate’s medical and/or mental health condition. Refer to SMD/MDS
Technical Reference Manual for the list of restrictions which are available in SENTRY.
Medical Idle. Maximum of three calendar days for recuperation from an acute illness or injury.
The inmate is restricted to his/her quarters except for meals, religious services, and medical callouts or pill lines.
Medical Convalescence. Maximum of 30 calendar days for extended recuperation from an
illness, injury, or surgery. Convalescence is specifically indicated to facilitate recuperation by

P6031.04 6/3/2014

57

not subjecting the inmate to the rigors of his/her job assignment, or to minimize the risk of injury
to the inmate, other inmates, or staff at the work site due to the inmate’s medical condition.
Inmates on convalescent status may attend other programs including education classes, drug
awareness programs, etc. Restrictions on recreational activities may be written on a case-by-case
basis. (For example, an inmate who is rehabilitating from orthopedic surgery may need access to
the recreation facilities to walk, or to do specific exercises prescribed by their health care
providers.)
b. Inmate Injury Assessment and Follow-up (BP-A0362). An inmate must complete a BPA0362 form for even the most minor injuries, regardless whether they are related to work,
recreation, assault, off-duty time, or occupational illness.
In each case the inmate should be quoted directly as to how the accident or occupational illness
occurred.
All injury reports must be reviewed and signed by a physician as soon as possible. Under
normal circumstances, this will occur the next working day.
A copy of the form will be forwarded to the Safety Manager.
c. Medical Footwear. The Bureau is responsible for providing one pair of safety shoes to each
inmate, suitable for their job assignment. The Program Statement Inmate Personal Property
lists other types of shoes which inmates may bring into the institution, or purchase at their own
expense.
Occasionally, custom shoes or orthotic devices may be medically necessary to accommodate a
significant foot deformity or to decrease the chance of injury to feet with impaired sensation.
For example, an inmate with a diabetic neuropathy may need an extra deep, extra wide toe box in
their work shoe in order to minimize irritation.
The Clinical Director must approve all requests for purchase of custom shoes and/or orthotic
devices.
Custom shoes or orthotic devices will be purchased through the institution Health Services Cost
Center.
d. Feminine Hygiene Products. The HSU will provide only medically indicated feminine
hygiene products. The institution will stock sanitary napkins.

P6031.04 6/3/2014

58