Illinois Administrative Code › Title 77 - PUBLIC HEALTH › Part 641 - SCHOOL-BASED/LINKED HEALTH CENTERS › Section 641.100 - Data, Medical Record Keeping, Exchange and Confidentiality

Current through Register Vol. 48, No. 28, July 12, 2024
a) The Center will develop a health record
			 system that provides for consistency, confidentiality, storage and security of
			 records for documenting significant student health information and the delivery
			 of health care services. (See Problem-Oriented Medical Record System and
			 Medical Record Management Guidance in Section
			 2200.50(c).)
1) The Center must maintain a single
			 confidential medical record for each student receiving services. The medical
			 record must be kept in a physically secure manner that protects it from
			 unauthorized use.
2) The Center's
			 health records must be maintained in a manner that is current, detailed,
			 confidential and organized, and promotes effective student care.
3) The Center may separately maintain medical
			 records needing a higher level of confidentiality, including, but not limited
			 to, mental health, substance abuse, family planning and HIV testing records,
			 provided that there is an effective cross referencing system. Access to such
			 records must be restricted to authorized personnel.
4) The Center must have written policies that
			 address exchange of health information verbally and/or faxed to insurers,
			 managed care entities and the student's primary care physician.
5) The Center's health records must contain
			 sufficient information to justify the diagnosis and treatment and to accurately
			 document all health assessments and services provided to the student,
			 including:
A) a signed consent for treatment
			 identifying services that may be provided in the Center;
B) the student's name and ID number on each
			 page in the record;
C)
			 personal/biographical data including address, home telephone, work phone for
			 parent(s), type of insurance, managed care entity's name/telephone number and
			 emergency contact;
D) health care
			 provider identification;
E) dated
			 entries;
F) legible records (errors
			 in charting shall have a single line drawn through, with the date and
			 practitioner's initials written above);
G) significant illnesses and medical
			 conditions;
H) medication allergies
			 and adverse reactions prominently noted in the record; if no known allergies or
			 history, note appropriately;
I)
			 appropriate notations concerning use of cigarettes, alcohol and illegal
			 substances, and other high-risk behaviors;
J) written history and physical documents
			 with appropriate subjective and objective information for presenting
			 complaints;
K) laboratory and other
			 studies ordered, as appropriate, with documented results/findings;
L) working diagnoses consistent with
			 findings;
M) treatment plans
			 consistent with diagnoses;
N)
			 encounter forms or notes with specifics regarding referrals, release of
			 information, follow-up care, calls or visits;
O) student's refusal of recommended
			 treatment;
P) notation of
			 unresolved problems from previous office visits addressed in subsequent
			 visit;
Q) record of after-hours
			 care (e.g., emergency room utilization);
R) if a consultation is requested, a note
			 regarding the results of the consultation;
S) consultation, lab and imaging reports
			 filed and initialed by primary care provider;
T) evidence that potential risk to the
			 student from diagnostic or therapeutic procedure has been discussed and
			 student's response;
U) evidence
			 that preventive screening and education services are offered in accordance with
			 the Center's or its sponsoring agency(ies);
V) a record of prescriptions obtained from
			 and/or provided by the Center;
W)
			 signed release of information forms, as appropriate, that are dated, identify
			 what is to be released and to whom, and length of time consent covers and/or is
			 valid;
X) restricted release
			 information practices (i.e., family planning, STDs, substance abuse, mental
			 health) conforming to federal governing laws. (See
			 325 ILCS
			 10/1, 410 ILCS 210/1, 2, 3, 4 and 5,
			 410
			 ILCS 70/5410 ILCS 305/9k, 410 ILCS 325/3,
			 405 ILCS
			 5/3-500 -510.)
6) The Center will request information
			 regarding previous health history at the time of enrollment to be included in
			 the health record, including:
A) past medical
			 and psychological history, including serious accidents, operations, illnesses,
			 prenatal care, births, substance abuse and mental health needs;
B) immunization records.
7) Records shall not be removed from the
			 Center.