1 Are inmates that are placed on suicide watch seen daily by mental health staff and medical staff
on weekends and holidays and documented in the Mental Health Section of the chart?
2 Are mental health and medical visits documented for inmates on suicide watch?
2 Is Mental Health Disposition Form 1103-44 being completed by Mental Health staff or Nursing
Staff with verbal orders from Mental Health Staff?
4 Is Mental Health Disposition Form 1103-44 being review and updated daily as needed?
3 Are inmates on suicide watch being issued only items authorized in the Suicide Watch Order?
6 Are inmate placed on a 10 minute suicide watch checked at random times not to exceed 10
minutes between each check?
3 Are inmates on suicide watch medications change to unit dose?
8 Are checks on inmates placed on 30 minute mental health watch conducted at random times not
to exceed 30 minutes between each check?
4 Are inmate placed on a suicide or mental health mental only removed from watch by a licensed
mental health professional?
5 Are inmates followed up within three (3) days of watch discontinuation and then seven (7) days
after that date?
[Mental Health Technical Manual, Chapter 2, Section 8.0]
Oral Care (Dental)
1 Is an oral examination performed by a dentist within 30 days of admission to ADC?
2 Is instruction on oral hygiene and preventive oral education given within one month of admission
to ADC?
3 Are there inmates waiting over 90 days for routine dental care?
4 Are 911's seen within 24 hours of HNR submission?
5 Are treatment plans developed and documented in the medical record?
6 Are daily inventories for all dental instruments being conducted before the first patient and after
the last?
7 Are all supplies that have an expiration date checked monthly?
8 If items are within 30 days of expiration, are they flagged and disposed of when they expire?
9 Are X-Rays taken of the tooth/teeth that are addressed during an emergency (911) visit?
10 Is the dental wait time log/report being maintained?
11 Is the MSDS binder being maintained?
12 Are patients provided with the medications that are prescribed by the dentist?
13 Are equipment repairs being addressed in a timely manner?
14 Are all orders for materials/supplies being fulfilled in a timely manner?
15 Are dental entries complete with military time and signature over name stamp?
16 Is treatment plan section C and priority section D of the dental chart completed?
17 Is the X-Ray certification/registration certificate posted in the dental clinic?
18 Are weekly SPORE testing logs available for the Autoclaves?
19 Is there a mechanism in place for immediate notification of a positive SPORE count?
Segregated Inmates
1 Are medical records being review for contraindications by nursing when notified an inmate has
been placed in administrative segregation and documented in the chart?
PRR ADC00147

Charging
1 Are appointment list forwarded daily to inmate banking? [HSTM Chapter 5, Section 8.0]
2 Are staffing trained on charging procedures?
3 Does appointment sheets reflect if there is a charge or no charge?
4 Are inmates signing the health appointment logs?
5 Does a review of appointment logs and medical encounters reflect appropriate charges?
Diagnostic Services
1 Does the responsible health authority maintain documentation that on-site diagnostics services
are certified or licensed (and posted)? [NCCHC Standard P-D-04]
2 Is there a procedure manual if a facility provides on-site diagnostic services including protocols for
calibration of testing devices (available to staff)? [NCCHC Standard P-D-04]
3 Do facilities with full-time health staff have multiple-test dip-stick urinalysis, finger-stick glucose
tests, peak flow meters, stool blood-testing material, and if applicable, pregnancy tests? (Post
orders for these tests?) [NCCHC Standard P-D-04]
4 Are laboratory tubes checked monthly for expiration?
5 Does radiology regularly monitor levels of exposure through dosimeters? [NCCHC Standard P-D04]
Hospital Specialty Care
1 Does each community hospital or off-site specialty service used have a written agreement that
outlines terms of care to be provided?
[NCCHC Standard P-D-05]
2 Do agreements with outside providers or off-site facilities require that a summary of treatment
provided and any follow-up instructions (this follow up information is to accompany the inmate upon
return to the facility)? [NCCHC Standard P-D-05]
3 Does the inmate get transferred to the hospital or clinic with a summary of the health record?
Emergency Services
1 Is an emergency/after hours on-call physician, mental health, dental roster available to nursing
staff? [P-E-08]
2 Are emergency drugs, supplies, and medical equipment regularly maintained (is there proof of
routine monthly inventory of Man-down Bag and no expired supplies)? [P-E-08]
3 Is (are) an AED(s) available, checked for fully functioning batteries and new pads? Is the location
clearly marked or known? [P-E-08]
4 Are nurses familiar with off site emergency transport procedures? [P-E-08]
5 Are there "Emergency Nursing Proctocols" in place and utilized?
6 Is the facility using a Medical Appointment List Form marked "ER" for inmates brought to health
unit to be seen as an emergency? [P-E-08]
Continuity of Care During Incarceration
1 Are ordered tests or specialty consultations completed in a timely manner and there is evidence
in the record of ordering clinicians review of the results?
2 When an inmate returns from hospitalization, does the physician see the patient, review the
discharge orders, and issue follow-up orders as clinically indicated?
3 Do clinicians use diagnostic and treatment results to modify treatment plans as appropriate?
4 Are individual treatment plans used to guide treatment for episodes of illness? Does the format
include, at a minimum, the frequency follow-up for medical and diagnostic testing and therapeutic
regimens and when appropriate, instructions about diet, exercise, adaptation tot he correctional
environment and medication?
PRR ADC00151