Service Delivery Obligations
Providers must provide all clinical documentation to California Correctional Health Care Services (CCHCS) within 48 hours of a visit. The documentation be sufficient to support continuity of care within the institution, and any other required reports, including, but not limited to:
- Brief operative notes.
- Clinical notes.
- Discharge summaries.
- Laboratory test results.
Providers who fail to provide clinical documentation within 48 hours may be subject to delay in payment or denial, until documentation is received.
Providers performing hospital services must issue a written discharge summary and/or transfer summary, for a hospital discharge of a CDCR patient back to the appropriate CDCR institution, skilled nursing facility (SNF), or DJJ facility.
The discharge or transfer summary precedes or accompanies the CDCR patient1 when discharged. The discharge and transfer summary must be signed by a physician and include the following essential information:
- Dietary requirements.
- Known allergies.
- Imaging studies ordered.
- Known allergies.
- Lab tests ordered.
- Needed follow-up appointments.
- Recommended activities.
- Referrals for additional care.
- Rehabilitation potential.
CCHCS may request hospital providers to use a standardized discharge summary form, created by CCHCS. A sample discharge summary form can be found in the operations manual. In the event labs or other test results are pending when discharge summaries are issued, providers must provide an updated report within 24 hours of receipt for labs or test results. Upon request, network hospitals must grant CCHCS clinical staff access to hospital medical records systems, if feasible.
Providers must give the Institution CEO/CME or the DJJ CMO a full, dictated or written formal discharge summary within three days of the CDCR patient1 discharge in all cases. The discharge and/or transfer summary should include the staff physician's recommendations for continuance of care for the CDCR patient.