AGENCY: Department of Health and Human Services. Division of Substance Use and Mental Health. State Hospital

SERIES: 8647
TITLE: Patient incident reports
DATES: 1980-2021.
ARRANGEMENT: Chronological.

DESCRIPTION: These are reports documenting incidents of patient aggression, accidents, escape, death, or staff errors. They are also used for evaluating the quality of intervention and/or interaction by the State Hospital staff when secluding or mechanically or physically restraining patients.

They include Escape Incident Reports, Medication Error Reports, Special Progress Notes, and Incident Report: gives date, time, and place of escape; the patient's name and identification number; the events and patient behavior preceding the escape; a description of where the patient was and why he/she was there; the names of key witnesses; the immediate actions taken (police notified, physician, family notified, etc.), the name of the physician notified and the time of notification; the physician's instructions; the name and position of the person reporting the escape; the signature of the RN on duty; a physical examination of the patient if necessary, the date, time and physician comments; the date, time, and comments of any ward review; the total number of hours the patient was away; the patient's status at the time of review; and the signature of the reviewer, place of error; a description of the event; the name of a staff witness; the immediate actions taken (first aid, vital signs taken, etc.), the instructions given; the signature of the duty nurse; a follow up report on actions taken; the signature of the supervising nurse if restraints or seclusion given, the type, the hours, and the reason for the action; actions taken in lieu of restraints such as verbal interaction or medication; instruction given; the date, time, and place of death; the names of staff witnesses; the medications and treatment given 24 hours prior to death; the activities 24 hours prior to death; the name of the physician and administrative director notified and the time of notification; the name of the person reporting the death; the name of the county coroner notified and the date and time of notification; the date and time death was pronounced and the number of hours the patient was dead; and the date the death certificate was completed.

RETENTION

Retain for 7 year(s) after separation or until date of birth

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

Retention and disposition for this series were specifically approved by the State Records Committee.

APPROVED: 10/2003

FORMAT MANAGEMENT

Computer data files: For records beginning in 1998 and continuing to the present. Retain in Office for 7 years after adult patient is discharged or until discharged juvenile is 18 plus 4 years and then delete.

Paper: For records prior to and including 1998. Retain in Office for 7 years after adult patient is discharged or records scanned or until discharged juvenile is 18 plus 4 years or scanned and then destroy.

APPRAISAL

Administrative Legal

This appraisal is based upon the desire of the agency to maintain these records for a retention period consistent with the patient case records (see record series 8642). This retention exceeds the statute of limitations for negligence or wrongful death suits as stated in UCA 78-12-28 (2001).

PRIMARY DESIGNATION

Controlled. Utah Code 63G-2-304 (2008).