SOP_NUMBER: 508.09
TITLE: Mental Health Records
REFERENCE_CODE: VG20-0001
WORD_COUNT: 2329
POWERDMS_URL: https://public.powerdms.com/GADOC/documents/106271
URL: https://gps.press/sop-data/508.09/
ATTACHMENTS:
1. Mental Health Cover Sheets and Mental Health Record Documentation
URL: https://gps.press/sop-data/508.09-att-1/
2. Group Treatment Case Notes
URL: https://gps.press/sop-data/508.09-att-2/
3. Records Inventory
URL: https://gps.press/sop-data/508.09-att-3/
4. Mental Health Diagnosis List
URL: https://gps.press/sop-data/508.09-att-4/
5. Group Attendance Roster
URL: https://gps.press/sop-data/508.09-att-5/
========================================================================
FULL TEXT:
========================================================================
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 1 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
**I.** **Introduction and Summary:**
All mental health information will be regarded as confidential, available to
authorized users and released in accordance with federal and state law and
departmental policy. This procedure is applicable to all Georgia Department of
Corrections (GDC) facilities with a mental health mission.
**II** . **Authority:**
A. O.C.G.A.: §§50-18-72, 24-9-47, and 37-3-162;
B. 45 C.F.R. §§ 164.512 and 164.508;
C. GDC Standard Operating Procedures (SOPs): 101.07 Open Records Requests,
219.04 Retention Schedule for Facility Offender-Medical Files, 507.02.01 Health
Record Management, Format and Contents, 507.02.02 Confidentiality of the
Health Record and Release of Information, 507.02.03 Transfer and Retention of
Health Records, 508.06 Activity Therapy Services, 508.10 Confidentiality of
Mental Health Records, 508.14 Mental Health Reception Screen, 508.16 Mental
Health Levels of Care, 508.21 Treatment Plans, 508.30 Mental Health Acute
Care Unit, and 508.33 Transfer of Offenders with Serious Mental Illness;
D. NCCHC Adult Standards;
E. NCCHC Juvenile Standards; and
F. ACA Standards: 2-CO-4E-01, 5-ACI-6A-29, 5-ACI-6C-03 (Mandatory), 5-ACI
6C-11, 5-ACI-6D-05, 5-ACI-6D-07, 4-ALDF-4C-27, 4-ALDF-4D-13
(Mandatory), and 4-ALDF-4D-14 (Mandatory).
**III. Definitions:**
A. **Confidentiality** - An expressed or implied promise not to divulge or share
certain information except for narrow and defined circumstances. This protection
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 2 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
of information from unauthorized Disclosure is a result of a professional
relationship afforded by professional codes of ethics.
B. **Disclosure** - Disclosure is the act of transmitting or communicating mental
health matters to a person who would not otherwise have access thereto.
**IV.** **Statement of Policy and Applicable Procedures:**
A. Ownership of Mental Health Records and Mental Health Information:
1. A mental health record will be maintained on every offender receiving mental
health services in the custody of the Georgia Department of Corrections.
2. The mental health record is the property of the Georgia Department of
Corrections and will be maintained in accordance with professional standards
and practices governing mental health record administration.
3. Except as identified in this standard operating procedure, information from
the offender’s mental health records will not be included in institutional or
central office files.
4. All mental health rosters and logs will be maintained in a binder separate
from the mental health record.
5. If Telehealth is used for patient encounters, the plan includes policies for:
a. Patient consent;
b. [Confidentiality/protected health information;](javascript:standardsMaster.SelectTreeNode(3507044);)
c. Documentation; and
d. [Integration of the report of the consultation into the primary health](javascript:standardsMaster.SelectTreeNode(3504928);)
care record.
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 3 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
B. Records (Organization):
1. The mental health record will be divided into nine sections (Attachment 1
Form M20-01-01) consisting of the following documents in descending
chronological order (with the most recent on top):
a. Section 1 - Progress Notes:
1) Progress notes should include clinical encounters/notes made by any
member of the treatment team, including mental health counselors,
mental health technicians, behavior specialists, activity therapists,
psychologists, psychiatrists, and mental health nurses (SOP 508.10,
Attachment 2 - Form M20-02-02 and Attachment 2B – Form M2002-02B).
2) Non-adherence documentation (physical health form P33-0003.01).
3) Group session notes and/or group session summaries (Attachment 2
Form M20-01-02).
4) Acute Care Unit (ACU) discharge summary (SOP 508.30,
Attachment 2 - Form M70-01-02).
5) Mental Health Services Transfer Summary Form (SOP 508.33,
Attachment 1 - Form M80-01-01).
6) Integrated Treatment Facility’s documentation – Monthly Summary
Report.
b. Section 2 - Treatment Plans:
1) Mental Health Diagnosis List (Attachment 5 - Form M20-01-05).
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 4 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
2) Initial Treatment Plan (SOP 508.21, Attachment 1 - Form M50-01
01).
3) Comprehensive Treatment Plan (SOP 508.21, Attachment 2 - Form
M50–01-02).
4) Comprehensive Treatment Plan Review (SOP 508.21, Attachment 3
Form M50-01-03).
5) Activity Therapy Assessment and Plan (SOP 508.06, Attachment 1
Form M56-01-01).
6) Mental Health Profile Form (diagnostic facilities only).
7) Integrated Treatment Facility’s documentation – Phase Up
Progression Forms.
c. Section 3 - Previous Records:
1) Previous treatment records from other agencies such as the
Department of Human Resources, private hospitals, or mental health
professionals.
2) Records from local school systems.
3) Copies of Department of Human Resources or Georgia Department of
Corrections forms used to request the above records (e.g., See SOP
508.15 Attachment 3 - Form M31-01-03).
4) Integrated Treatment Facility’s documentation - Department of
Community Supervision and other agency documentation.
5) If no prior records exist a brief note stating, “no prior records exist”,
may be included in this section. If prior records are unattainable due
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 5 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
to juvenile record statutes or lack of sufficient information to obtain
records, a brief note stating “no records available” may be included in
this section.
d. Section 4 - Evaluations:
1) Mental Health Reception Screen (SOP 508.14, Attachment 1 - Form
M30-01-01).
2) Mental Health Referral (SOP 508.19, Attachment 1 - Form M35-01
01).
3) Mental Health Evaluation for Services (SOP 508.15, Attachment 1
Form M31-01-01).
4) Mental Status Evaluation (SOP 508.15, Attachment 2 - Form M31
01-02) (when not used as an attachment to another form).
5) Mental health related consultations, (e.g., neurological examinations).
6) Psychiatrist/Psychologist Initial Evaluations (SOP 508.24,
Attachment 6, Form M60- 01-06).
7) Psychiatrist/Psychologist Transfer Evaluations (SOP 508.24,
Attachment 5 - Form M60-01-05).
8) Parole Evaluations (SOP 508.15, Attachment 6 - Form M31-01-06).
9) Test results (including the originals of all test record forms).
10) Evaluations of test results.
11) Sexual Allegation Evaluations (SOP 508.22, Attachment 4 - Form
M55- 01-04).
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 6 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
12) Mental Health Disciplinary Evaluations (SOP 508.18, Attachment 1
Form M34-01- 01, and Attachment 2 - Form M34-01-02).
13) Copy of mental health staff’s response to a referral from another staff
member.
14) Suicide Risk Assessment Instrument (SOP 508.29, Attachment 1
Form M69-01-01).
15) Activity Therapy Assessments (SOP 508.06, Attachment 6 - Form
M56- 01-01).
16) Integrated Treatment Facility’s Documentation – Addiction Severity
Index, Four Quadrants of Care, Learning Experiences (LEs), Staff
Awareness documentation, other evaluations
e. Section 5 - Medical-legal documentation:
1) Consent to Treatment (SOP 508.10, Attachment 1, Form M20-02- 01).
2) Medication Informed Consent (SOP 508.24, Attachments 1a - 1h,
Form M60-01-01).
3) Refusal of Treatment (SOP 508.10, Attachment 4, Form M20-02-04).
4) Authorization for Release of Information (SOP 508.15, Attachment 3,
Form M31-01-03) when used to grant authority for the GDC to
release information to another party.
5) Involuntary Medication documents (SOP 508.26, Attachments 1 - 7,
Forms M66-01-01 through M66-01-07).
6) Vitek documents (SOP 508.25, Attachments 1 - 5, Forms M65-01-01
through M65-01-05).
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 7 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
7) Current prison psychiatric facility admission/discharge forms.
8) Department of Human Resources involuntary hospital documents
(Form DHR 1013).
9) Heat Precautions (SOP 508.24, Attachment 4, Form M60-01-04).
f. Section 6 - Physicians’ Orders (may also refer to the medical record for
this information):
1) Copy of physicians’ mental health related orders.
2) Copies of mental health related lab work requested by the psychiatrist.
3) Abnormal Involuntary Movement Scale (AIMS) Evaluations (SOP
508.24, Attachment 2 - Form M60-01-02).
g. Section 7 - Miscellaneous:
1) Letters from the offender.
2) Family letters.
3) Mental health-related incident reports when not part of a restraint
package.
4) Mental health-related use of force statements not related to restraints.
5) Referral forms to community agencies or transitional centers (SOP
508.35, Attachment 1 - Form M85-01-01).
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 8 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
h. Section 8 - Acute Care Unit/Crisis Stabilization Unit and Restraints:
1) Admission and discharge notes for psychiatry, nursing, and mental
health counseling.
2) All restraint documentation and a copy of the Acute Care Unit/Crisis
Stabilization Unit chart package.
3) Documents to be filed here are:
i. Progress notes pertaining to the restraint episode;
ii. Psychiatrist’s order for restraints;
iii. Mental health professional’s log (only individual offender log);
iv. Correctional officer/medical staff’s log for restraint (only
individual offender log);
v. Medical staff/correctional officer 24-hour log (only individual
offender log);
vi. Daily notifications to the warden;
vii. Use of force reports; and
viii. Incident reports related to the restraint episode (All of these will
be contained in the Acute Care Unit/Crisis Stabilization Unit chart
package).
i. Section 9 - Integrated Treatment Facility Documents: Overflow from
sections 1 & 4. (Group notes, learning experiences, staff awareness
documentation, etc.)
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 9 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
2. Each section will be labeled with the appropriate section label provided in
SOP 508.10, Attachment 1 - Form M20-01-01. In charts that have only six
divisions, the labels will be inserted as follows:
a. Division 1 = section 1;
b. Division 2 = section 2;
c. Division 3 = section 3;
d. Division 4 = section 4 and section 5;
e. Division 5 = section 6; and
f. Division 6 = section 7, 8 and (at Integrated Treatment Facilities) section
9.
3. No locally produced or unauthorized forms will be acceptable.
C. Mental Health Documentation in the Medical Record:
1. The following documents are to be placed in the mental health section
(section 5) of each offender’s medical record. (See SOP 507.02.01, Health
Record Management, Format and Contents):
a. Mental Health Evaluation of Services Form (SOP 508.15, Attachment 1
Form M31-01-01).
b. Mental Health Reception Screen Form (SOP 508.14, Attachment 1
Form M30-01-01).
c. Copy of comprehensive treatment plans (SOP 508.21, Attachment 2
Form M50-01-02).
d. Previous hospital records, if applicable.
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 10 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
e. Psychologist’s interpretation of test results.
f. Initial psychiatrist/psychologist evaluation (SOP 508.24, Attachment 6
Form M60-01-06).
g. Discharge summary note (when an offender is removed from the
caseload. (SOP 508.16, Attachment 1 - Form M32-01-01).
2. Restraint as part of Acute Care Unit/Crisis Stabilization Unit documentation
will be placed behind the Infirmary Section (section 6) of the medical record.
3. The original Acute Care Unit/Crisis Stabilization Unit chart package will
be placed behind the Infirmary Section (section 6) of the medical record.
4. Items in C1 (a-f) above will be retained in the most current medical record, if
more than one volume exists.
D. The mental health record technician will close the mental health record upon an
offender’s release/discharge from the mental health caseload (discharge, release,
level I status or death). All information will be removed from the mental health
record and will be placed in descending order with the Mental Health Discharge
Summary placed on top in the mental health section of the medical record (See
SOP 507.02.03, Transfer and Retention of Health Records).
E. At probation detention centers the mental health file is maintained in the medical
file and should be separated by the eight sections and in chronological order.
F. A physical inventory of all mental health records will take place at least monthly
with the results forwarded to the mental health unit manager, who will take
appropriate measures to ensure the accountability of all records (Attachment 4 Form M20-01-04).
G. Inactive health record files are retained as permanent records in compliance with
the legal requirements of the jurisdiction. Health record information is
|GEORGIA DEPARTMENT OF CORRECTIONS
Standard Operating Procedures|Col2|Col3|
|---|---|---|
|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|**Policy Name:**Mental Health Records|
|**Policy Number:** 508.09|**Effective Date:** 03/01/2022|**Page Number:** 11 of 11|
|**Authority:**
Commissioner|**Originating Division:**
Health Services Division
(Mental Health)|**Access Listing:**
Level II: Required Offender
Access|
transmitted to specific and designated physicians or mental health facilities in the
[community upon the written request or authorization of the offender.](javascript:standardsMaster.SelectTreeNode(3505056);)
**V.** **Attachments:**
Attachment 1: Mental Health Cover Sheets (M20-01-01)
Attachment 2: Group Treatment Case Notes (M20-01-02)
Attachment 3: Records Inventory (M20-01-04)
Attachment 4: Mental Health Diagnosis List (M20-01-05)
Attachment 5: Group Attendance Roster (M20-01-06)
**VI. Record Retention of Forms Relevant to this Policy:**
Upon completion, Attachments 1, 2 and 5 shall be placed in the offender’s mental
health file. At the end of the offender’s need for mental health services and/or
sentence, the mental health file shall be placed within the offender’s health record
and retained for 10 years. Attachments 3, 4 and 6 will be retained in the mental
health area until obsolete or replaced.