It is important for health care providers treating individuals in prison or jail to record pertinent clinical information regarding each person's condition and treatment throughout his or her incarceration. Such records ensure that ineffective treatments are not repeated and that beneficial treatments are continued while the person remains in a correctional facility. In addition, the records can be useful for making future referrals and for providing information to health care providers in the community. While the full panoply of medical records may or may not be transferred to a community-based provider upon the individual's release, the records may serve as a resource for community-based providers who wish to have a more detailed medical history for a patient who was once incarcerated. Moreover, the records concerning his or her condition, treatment, status, and medication provide a helpful basis of information for the person charged with creating a summary document at the time of an individual's discharge. (See Policy Statement 20, Planning Continuity of Care, for more on creating a portable "summary health record" for each person at the time of his or her discharge from prison or jail.)

Corrections systems must customize their medical record-keeping systems to meet their resources and needs. Ideally, all medical records should be recorded in an electronic format accessible to medical providers both in the institution and in the community. (See Policy Statement 5, Promoting Continuity and Integrated Case Management, for more on computerized information management systems.) Such a system would ensure continuity of care between providers both inside and outside the facility and would alleviate the need for the person who has been incarcerated to provide his or her own medical history (from memory or on paper) each time he or she visits a new provider. (See sidebar "Confidentiality and the Health Insurance Portability and Accountability Act.")

Example: Hampden County Correctional and Community Health Program, Hampden County Sheriffs Department (MA)

Hampden County Correctional Center uses an extensive shared database for inmate records, beginning with each person's health assessment information. The electronic system not only enables a diverse group of project partners (sheriff, jail medical director, local community health centers, providers, etc.) to share medical treatment and diagnosis information, but also incorporates an electronic pharmacy system.

In practice, many corrections systems still rely on a paper filing system to manage inmate health records. Even paper files, however, can be kept in a central location within the correctional facility and can be organized in a systematic manner that is accessible to all health care providers who have been trained to use the system. To the extent that corrections officials work with community-based partners to provide medical care (as suggested in Recommendation a, above) the community partners should have access to the records as well.