Ombudsman Standards for Visiting Prisons and Places of Detention - page 31

UNOFFICIAL TRANSLATION BY THE INDEPENDENT OMBUDSMAN’S OFFICE
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2 –Patient care
Indicators
The prisoners or detainees are able to see health-care personnel
The medical record for each prisoner or detainee submitted to health-care
personnel. It contains an assessment and a care plan that conform to professional
guidance from the regulatory bodies.
Any contact with a doctor or other health care professional is recorded in the
custody record, and a record made of any medication provided.
The appropriate medicine is available
The generic medicine for common pathological cases is available.
Evidence
Staff
Ask
What the procedure is for calling a health professional
What the arrangements are for recording health interventions and transferring
information about medication to the custody record
How the consent of prisoners or detainees is obtained and how the results of
clinical examinations are shared with prisoners or detainees
Prisoners or detainees
Ask
Whether the health needs of the prisoners or detainees are met.
Whether the prisoners or detainees have made any complaints concerning health
care provision
If the results of a detainee’s clinical examination are provided to him.
Whether their consent is sought in advance.
Documentation
Check
That a sample of clinical records from the last six months includes the prisoner or
detainee’s signature to determine consent for the sharing of information, the
problems experienced, the diagnosis, treatment and care plan
Referral letters
That records are kept confidentially
Complaints concerning health care provision
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