Army Memo re: Custody and Control of Medical and Dental Records at the Guantanamo Bay Detention Hospital

Army memo on how staff at Guantanamo hospital are to secure detainee medical and dental records. It states: i) At no time will active Detainee medical/dental records leave the custody of Detention Medical staff; ii) All dental records will be kept in the Detention Hospital Dental Clinic; iii) for Detainees admitted to Delta Block, these medical records will remain stored at the Delta Block; and iv) A complete inventory of all medical/dental records will be conducted by the OIC or the JMG. Other policies also apply.

Doc_type: 
Non-legal Memo
Doc_date: 
Wednesday, June 1, 2005
Doc_rel_date: 
Wednesday, June 14, 2006
Doc_text: 

DETENTION HOSPITAL SOP NO: 009
GUANTANAMO BAY, CUBA
Title: CUSTODY AND CONTROL OF Page 1 of 7
MEDICAL/DENTAL RECORDS Effective Date: 01 JUN 05
SCOPE: JOINT MEDICAL GROUP (JMG)

I.EENCLOSURE:
(1)
NAVMED FORM 6150/7

(2)
Sample, Record Closure Insert

(3)
Sample, Chain of Custody

II. BACKGROUND:
On arrival to Guantanamo (GTMO), all Detainees have a medical and dental record
established to document their healthcare while in custody. Joint Medical Group (JMG)
and Detention Hospital personnel will exercise control, custody and management of all inpatient and outpatient medical/dental records with guidance from applicable service instructions. This Standard Operating Procedure provides guidance on the storage, handling and accountability of all healthcare records in JMG custody.
III. POLICY:
A secure, climate-controlled environment is required for the storage of all active and retired Detainee medical records. All Detainee healthcare information will be treated as sensitive material. All medical/dental records will be maintained in a secure storage device if the space is not continuously manned.
At no time will active Detainee medical/dental records leave the custody of Detention Medical staff. Whenever a Detainee is admitted to the Detainee Acute Care Unit (DACU) at the U.S. Naval Hospital, the custody of the medical record will reside with Detention Medical staff working in that location. Any exception to this policy will be cleared by the Senior Medical Officer (SMO), Officer in Charge (OIC) or the JMG Commander.
IV.
PROCEDURES:

A.
Active Outpatient Records

1.
The Detainee's Internment Serial Number (ISN) will be used as the primary filing number for all Medical and Dental records.

2.
All active outpatient medical records will be kept in the Delta Detention Clinic at all times: Enclosure (1), commonly known as the "Pink Card", will be completed for any record transported out of Delta Clinic.

3.
All dental records will be kept in the Detention Hospital Dental Clinic. These records will not be removed from this space without the express approval of the Dental Officer, the Senior Medical Officer (SMO) or the Detention Medical Officer in Charge (OIC). The dental record will accompany all Detainees undergoing oral surgery procedures at U. S. Naval Hospital GTMO.

4.
The outpatient medical record will accompany all Detainees admitted to the Detention Hospital or the DACU. The record will be stored in a cabinet or file drawer at the detention hospital 81111111111111111 ¦11111the DACU 111111111111111‘ .6 (7-)

_t) (2)
-
5. Delta Clinic will charge out all outpatient medical records for Detainees admitted to Delta Block. These medical records will remain stored at the Delta Block
(2)
6.
The Director for Clinical Services will maintain a listing of all outpatient medical/dental records in Delta Clinic's possession sorted by ISN number and the number of volumes for each. The list will be compared to the Detainee camp roster maintained by J3. This list will be updated quarterly and a report submitted to the JMG Commander via the SMO and the OIC no later than 10 days after the end of each quarter.

7.
The Dental Officer will maintain a listing of all dental records in Dental's possession. This list will be updated quarterly and a report submitted to the JMG Commander via the SMO and the OIC no later than 10 days after the end of each quarter.

B. Active Inpatient Records
Inpatient records for Detainees still in custody will be considered active inpatient records.
1. Active inpatient records are maintained in a locked cabinet in the MEW
or at the Detention Hospital 40111MIllialif currently an inpatient. 6(2-)
2. They will be catalogued by ISN number.
DOD JUNEE 755
3.
Each admission will have a separate health record jacket and filed separately.

4.
The Director for Administration (DFA) is responsible for the maintenance and storage of these records.

5.
The DFA will maintain a listing of all active inpatient medical records sorted by ISN number and the number of volumes for each. The list will be updated quarterly and a report submitted to the JMG Commander via the SMO and the OIC no later than 10 days after the end of each quarter.

6.
Once a detainee is discharged from the Detention Hospital or the U.S. Naval Hospital DACU, a final administrative review of the record will be conducted prior to filing it in the algallffillinga b(0

C. Inactive Records
Medical/Dental records for detainees who have been permanently released from custody will be placed in an inactive status.
1.
Inactive Detainee medical/dental records, both inpatient and outpatient, are maintained in a secure storage device.

2.
Inactive records will be catalogued by ISN number.

3.
All records (inpatient, outpatient or dental) will be grouped together by ISN.

4.
Detainees who are permanently transferred from GTMO will have their outpatient medical record and their dental record closed. To close a medical record, enclosure (2) will become the topmost form of Part 2 in the outpatient medical records, inpatient medical records, and dental records. Enclosure (2) will be signed by the SMO for all medical records and by the Dental Officer for all dental records.

5.
All permanently transferred Detainees will have the inactive records (all volumes) bundled and forwarded to the JMG Commander. Enclosure (3) will accompany all transferred records, and the DFA and the JMG Medical Planner will keep a copy on file of each signed enclosure (3).

6.
The JMG Medical Planner will maintain a listing of all medical/dental records in their possession sorted by ISN number, record type, number of volumes for each and the date accepted into custody. This list will be updated quarterly and a report submitted to the JMG Commander no later than 10 days after the end of each quarter.

D. Missing Records
1. When a Detainee medical/dental record is unaccounted for, the record custodian will submit a memorandum to the JMG Commander via the OIC documenting the record as missing. The DFA or the JMG Medical Planner, as appropriate, will maintain a copy of this memorandum on file.
E. Record Inventory
1. A complete inventory of all medical/dental records will be conducted when the OIC or the JMG Medical Planner turn over.
F. Medical Evacuations
At no time will the original medical or dental record leave Guantanamo Bay, Cuba.
1.
If a Detainee requires medical evacuation from the island, a photocopy of the Detainee Medical and Dental record will be made.

2.
The copies will be clearly marked as duplicate across the cover sheet.

3.
The copies will remain in the possession of a JMG representative or designated medical authority at all times while undergoing medical care.

4.
When the final medical disposition is made on the detainee, the copies will
accompany the detainee back to Guantanamo Bay, Cuba.

5.
The copies will then be destroyed by the JMG Medical Planner.

HEALTH RECORD RECEIPT ALE cputanOuTA.40 DAIPOIUTION MOWNAVAIIE0 015017 (2.74).. Haa rims. earn. WNW
' tlikaaitali 5314
sonr41,4 mow
atittunzawar calx
now.aremeto io MC
ft:1MM

INSTRUCTIONS
This form is dedgrod for us* as a permanent record of receipt end
ditspositinn a Om HEALTH RECORD.
(A) Fat each NEALTN RECORD received. centogoto Men i thoomh 4
and lob in Its HEALTH RECORD
(41 Upon transfer cornplast kW 5 and atm Iona in psonansst

Mos
(C)..he.nerre . HEALTH RECORD is tamporarily removed from Mos eel* infoonsibm wander:I kr bake , end retain kern in
HEALTH RECORD Meg

FILE CHARGE-OUT
DATE RECEIVED BY ANO/OR LOCATFON
-..¦•¦••-E -¦
.
1.1 i GoappmersiEOfte-E7064120131

51N 0105-LF-200-0071
7111111/211
ti
HEALTH RECORD RECEIPT ALE et4AIMOUT A140 CIRPOSITION RECORD NAVMED pima (244) Nom ampE eksE 016001
IPIJIMALIt Mli
11.4045,1111:64
geozarcassor cm
worsts.** s, wit


INSTRUCTIONS This Torre is designed for use as a permanent' record of receipt six, diva:Wort of Its& rteALmt Recomo
/4) Tot es al NEAL711 RECORD tereilVari. complete Mast thrcx,ohd and lee in !no HEALTm RECORD (41 Upon twist°, compken taxa 5 art soon form m parmarwee Nes
(C) 161enerfre HEM.TH RECORD is Wernxtrarriy oultowal from Nees
enter OnDonnaton 0 fOofrd931 'Of belcve and Jetain form in HEALTH RECORD (lift
FILE CHARGE-OUT
DATE RECENED BY ANDIOR LOCATION
—......_E_.-..
E
1J 6 Gramirsard Pry**. 011me•.70.6002/4121

SIN 0105•1F-200-5071
VTR 110211
ISN: X)iX-XX-X..,OCX

RECORD
INACTIVATED

(DATE)E
SIGNED:

SMO DENTAL OFFICER
Enclosure (2)
DOD JUNE 760
DEPARTMENT OF THE NAVY
DETENTION HOSPITAL
JTF- GTMO-JMG,
APO-AE, 09360

5000 DD Sep YY
From: Officer in Charge, Detention Hospital, Joint Task Force, Guantanamo Bay, Cuba To: Commander, Joint Medical Group, Joint Task Force, Guantanamo Bay, Cuba
Subj: RECEIPT OF DETAINEE RECORDS
End: (1) Diskette With Detainee ISN's
(2) List of Enclosed Medical Records
1.
The enclosed Detainee records are forwarded along with enclosures (1) and (2) acknowledging transfer of custody to and receipt by the Joint Medical Group Commander. These records are no longer in the custody of the Detention Medical Administrative Department.

2.
If there are any questions in this matter please feel free to contact at ext. 3025.

OIC Detention Hospital JTF GTMO
Enclosure (3)
STANDING OPERATING PROCEDURES Medical Plans and Operations Guantanamo Bay, Cuba
_......_ _ _ REVIEWED AND APPROVED BY:
b( 6) 1 JUN 05
Officer In Charge Date

IMPLEMENTED BY:
) 31 MAY 05
Director for Administration Date

Senior Enlisted Advisor Date
ANNUAL REVIEW LOG:
By: • Date:
By: Date:
By: Date:
By: Date:
By: , Date:
By: Date:

SOP REVISION LOG:
Revision to Page: Date:
Revision to Page: Date:
Revision to Page: Date:
Revision to Page: Date:
Revision to Page: Date:
Revision to Page: Date:

ENTIRE SOP SUPERSEDED BY: ,
Title:
SOP NO: Date:

Doc_nid: 
4721
Doc_type_num: 
63