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OKLAHOMA DEPARTMENT OF CORRECTIONS
MEDICAL SERVICES DIVISION
DATA DEFINITIONS
DRAFT – Monthly Medical Activity Report (OP-140107) - DRAFT
Instructions: Please complete the following for the previous calendar month. By the 5th of the
current month, enter the data in the Medical Activity Report System and keep a copy for your files.
If you have any questions, please call the Medical Services Division.
Month/Year: _______________ Facility: ___________________________________________
SECTION ONE: MEDICAL ENCOUNTERS & SERVICES COORDINATED
AT FACILITY
Primary Care (NOTE: include all visits to physicians, nurses, PA, NP, etc.) (OP-140117)
Number of sick call encounters (1A-24)
Total sick call slips for medical, mental health, and dental.
Scheduled medical appointments (1A-25)
Physician
Number of visits performed by physician, PA, Nurse Practitioner, or Nursing staff.. Include pretriage, wound care, nursing protocols, dressing changes. Exclude physical exams, labs, x-ray,
and items reported elsewhere
Physician’s Assistant
Nurse Practitioner
Nursing Staff
Emergencies seen in the clinic
Unscheduled visits of an emergent nature. An unexpected health care need that cannot be
deferred until the next scheduled sick call or clinic. Includes all potentially life-threatening
circumstances and all contacts associated with significant potential for loss of limb or major bodily
function.
Total number of encounters in pill pass, KOP,
etc. (1A-36)
Pill line activity. Also include SHU pill encounters, insulin injections, oral and IM medications. We
are counting each time an inmate is seen.
After Hour Callbacks (OP-140101)
Physician
Physician’s Assistant
Nurse Practitioner
Nursing staff
Number of times staff returned to facility during month. For Mental Health staff, refer to the page
completed by them to get number for callbacks.
Dentist
Mental Health staff
Health Services Administrator
Other
SHU Medical Visits (OP-140117)
Nursing staff
Other
The number of visits to the SHU for medical activities. Only include nursing staff. Just put total for
“Other” – no need to itemize. See Mental health visits from the Mental Health page to include
here.
Medical Activity Restrictions (OP-140107)
Temporary inmate lay-ins
Medically unassigned
Short term with an estimated discharge date. “…medical, dental or mental illness or injury with an order from a
qualified health authority that restricts return to regular activities as documented in hours, days, weeks, or months.”
Long term. “… medical dental or mental health illness or injury with an order from a qualified health authority that
has no potential of return to regular activities.”
DRAFT - Monthly Medical Activity Report, DRAFT
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Medical Special Needs A medical condition that requires the need of assistant devices or inmate has a medical
impairment (OP-140133).
Number of inmates in wheelchair
Number of inmates who are vision impaired
Legally blind, cataracts, glass eye. Do not include inmates with just eyeglasses.
Number of inmates who are hearing impaired
Hearing aids
Number of inmates using walkers, canes,
crutches
Number of inmates using prosthesis
“A functional or cosmetic, artificial device that substitutes for a missing body part such as an arm,
leg, eye, or tooth.”
Therapeutic diets (OP-070202) “A diet prescribed by a health care practitioner as part of the patient’s medical treatment.”
Diet for Health (1A-30; 1A-31; 1A-32)
Diabetic diet, heart
Mechanical Soft (1A-30; 1A-31; 1A-32)
Dental diet
Renal Diets (1A-33)
Other
Liquid, allergy.
Testing and Screening Number of tests performed in your facility and how many tests performed in outside
facilities. Utilization of facilities due to not having the capability to perform the screenings in your facility. For
example, x-rays.
On-site Completed at
your facility
Test (limit to inmates)
Off-site
Contracted.
Activity not
completed at
facility
Test (limit to
inmates)
On-site Completed
at your facility
Off-site Contracted.
Activity not completed
at facility
PPD (1A-3)
Tuberculin skin test
Number of CXRs
sent to OSDH
How many chest x-rays were sent to the
Oklahoma State Department of Health?
Positive PPD reading (1A-1)
Include 10 x 10 results for regular population
AND 5 x 5 results for high risk population
X-ray Total
Include all x-rays of extremities, chest, etc.
but NOT dental.
Serious Injuries and Deaths A process of reporting critical occurrences (OP 140111, OP 140125, and OP 14029)
Assaults - inmate to inmate (6A-7)
Inmates only
Accidental (inmates) (6A-3)
Inmates only
Assaults - inmate to staff (6A-7)
Staff only
Work-related (inmates) (6A-3)
Inmates only
Sexual assaults - inmates and staff
Include staff.
Inmate to inmate
and inmate to staff.
Sports (inmates) (6A-3)
Inmates only
Self-mutilations (inmate)
Inmates only
Bloodborne pathogen exposures: staff
Staff only
Attempted suicides (inmates) (1A-9)
Inmates only
Bloodborne pathogen exposures: inmates
Inmates only
Deaths (include suicides and executions)
Inmates only –
includes suicides
and executions
Medication administration errors (1A-36)
Inmates only
Needle-stick injuries (staff) (1A-34)
Staff only
Pharmacy dispensing errors (1A-35)
Inmates only
Total medical grievances (inmates)
Inmates only
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Specific Illness Counts This section will capture data on incidence and prevalence for comparisons (OP-140137,
OP-140125, OP 140301; MSRM 140137-03, MSRM 140137-06)
Prevalence: Total
number of known
patients at facility
(includes newly
diagnosed)
Illness (Note: a patient with multiple diseases must be
counted for each category listed below)
Incidence: Number of
newly diagnosed patients
at facility within this month
Chronic/Serious Illness: “…a disease process or illness that persists over an extended period of time” An
illness that is either ongoing or recurring over a course of several months to years.
Asthma
Pulmonary
Includes COPD
Diabetes (1A-27)
Endocrine
Hypertension (1A-27)
Cardiovascular
Seizures
Cancer
Infectious/Communicable Disease “ a disease that can be transmitted between person to person”
Tuberculosis Disease
TB Infection: currently on treatment (1A-2; 1A-3)
AIDS/HIV (1A-6, 1A-7)
AIDS/HIV : currently on treatment (1A-7)
How many inmates with AIDS/HIV are on treatment at your facility?
Hepatitis A
Hepatitis B
Hepatitis C (1A-5)
STD (sexually transmitted diseases)
Other infectious/communicable disease (please list and total on this
line) (5A-1)
Hygiene related conditions (scabies, lice, fungal infections, etc.) (5a-1)
“Parasites that live on the outside of the host . Examples: fleas
and lice.”
Other
Specialty Care Visits (report only clinics that have been completed) (1A-18)
Specialty Care Not Completed (use additional sheets if necessary)
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SECTION TWO: COMMUNITY AND EMERGENCY CARE
Services provided outside your facility to inmates
Hospital Admissions and Emergency Care
Off-site emergency room visits Care for an inmate with an acute illness or unexpected health care need that cannot be treated at your facility (OP140118)
OU Medical Center
Local hospital
Hospital admissions from emergency room visits How many hospital admissions followed an emergency room visit? This includes admissions to
(1A-16)
Lindsay Hospital, OUMC, and local hospitals.
Hospital admissions from non-ER visits (1A-16)
How many regular hospital admissions? This includes admissions to Lindsay Hospital, OUMC, and
local hospitals.
Total number of hospital days during month
Number of inmates in hospital during month
Inmates in Medical Care Elsewhere
Inmates in nursing home
Inmates in palliative care
Facility Transfers to an Infirmary (other than your own) (OP 140119)
OSP
MBCC
LARC
DCCC
GPCF
This part is only to be filled when a facility transports inmate patients to an
infirmary. It captures the number of inmates that your facility moved to one of
the following facilities with an infirmary: OSP, MBCC, LARC, DCCC, GPCF.
Other (Total on this line and list below)
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SECTION THREE: SPECIALIZED TREATMENT UNITS AND CARE
Tab 3
Infirmary Report (NOTE: this section is only to be completed by the following facilities:
OSP, MBCC, LARC, DCCC, GPCF) Area within the confinement facility, accommodating two
or more inmates for a period of 24 hours or more, expressly set up and operated for the
purpose of caring for patients who are not in need of hospitalization or licensed nursing facility
placement, but whose care cannot be managed safely in an outpatient setting (OP-140119).
Total infirmary admissions this month (1A-15)
Total infirmary discharges this month
Tab 3
Women’s Health Care Report (NOTE: this section is only to be completed by the
following: MBCC, EWCC, LARC, KBCCC, TCC) (OP 140145)
Pap smears
Number of births – c-section (MSRM 140145-01)
Mammograms
Number of births – vaginal (MSRM 140145-01)
Number pregnant (new and current)
Tab 4
Mental Health Unit Report (NOTE: this section is only to be completed by the following
facilities: JHCC MHU, MBCC MHU, and OSP MHU) (OP-140127)
MHU referrals - referred and placed on
observation/evaluation status
MHU referrals – referred and not admitted to
observation/evaluation status
Number of inmates newly admitted to MHU
Number of inmates discharged from MHU
Tab 4
Private Facilities’ Medication Encounters to include prescriptions obtained from both
DOC pharmacy and private venders (NOTE: this section is only to be completed by
private facilities. Data for DOC facilities is collected from DOC pharmacy system) (OP140130)
Number of prescriptions (1A-35)
Number of psychotropic medications
Number of inmates on medication
Number of inmates on psychotropic medications
DRAFT - Monthly Medical Activity Report, DRAFT
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SECTION FOUR: MENTAL HEALTH SERVICES MONTHLY ACTIVITIES
Treatment or Contact
Number of individual inmates seen in individual therapy/counseling
Total number of individual therapy/counseling sessions
Psychiatrists
QMHP (qualified mental
health professional)
This is the number of inmates who have attended at least one
individual session with you. You are counting individual inmates
here so there should not be any duplication.
For this item, you are counting the number of individual sessions
that you provided. This should be at least be equal to the number
of inmates seen. It can be more if some inmates received more
than one session.
Number of individual inmate contacts in group therapy/counseling or
psycho-educational groups
How many inmates attended a group session this month?
Remember that an inmate will only be counted once for this item.
Total number of group sessions
How many group sessions did you provide this month?
Number of inmates administered a psychological battery (evaluation)
Number of inmates seen for crisis intervention
This is the number of inmates who took some type of psychological
test. Do not overcount here. If an inmate completed a WAIS one
day and an MMPI another, you only have one inmate to count.
Some inmates may seem to have a predisposition for a crisis every
week but you only count the inmate and not each episode.
Number of contacts seen for crisis intervention
Number of MHU therapeutic contacts (MHU facilities only)
How many times over the month did you have contact with inmates
in MHU? This may end up looking like an inflated number but you
are counting the number of contacts. It is possible that several
inmates are contacted every day.
Number of inmates seen for clinical interview and/or mental status
exams (other than SHU and LARC)
Again, you are counting inmates and not the number of exams or
interviews.
Number of inmate contacts during SHU semi-weekly reviews
Every other week, you may have an individual inmate contact at
RHU (SHU). For this item, how many times did you have contact
with an inmate on RHU (SHU)?
Number of inmates seen for 30 or 90 day SHU mental status exams
Again, you are counting the number of inmates and not exams.
Number of inmates participating in group psychological testing at
assessment center
Although this is testing at a group level, you want to ask yourself:
How many inmates went through group testing?
Number of inmates seen at assessment center for clinical interviews
Count the number of inmates and not interviews.
Number of incidents involving restraints
How many times was there an incident involving restraints?
Number of enforced medication incidents
Number of inmates on non-emergency involuntary medication.
Number of inmates on psychotropic medications
Number of inmates seen for psychotropic medication management
Number of contacts for psychotropic medication management
Total number of hours MH staff delivered in-service training (includes
both medical and non-medical staff)
Number of staff consultations
Number of after hour callbacks
How many times did you participate in an enforced medication
incident?
For this item, count the number of inmates on non-emergency
involuntary medication.
How many inmates you see are on psychotropic medications?
How many inmates did you provide psychotropic medication
management?
For this item, count the individual contacts with the inmate. For
example, the previous item could be 2 inmates seen for medication
management BUT there were 4 contacts since one inmate was
seen 3 times.
How many hours did you spend providing in-service training?
How many consultations did you provide to staff (all staff) this
month?
Count the number of time within the month that mental health staff
returned for a call
DRAFT - Monthly Medical Activity Report, DRAFT
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SECTION FIVE: DENTAL SERVICES MONTHLY ACTIVITIES
Tab 4
Clinic Visits & Requests For Care
Routine visits
Unscheduled visits/Emergency visits
Total visits failed/canceled by clinic or patient
Total clinic visits
Total sick call requests
Dentist
Hygienist
Appointed patients
Visits by patients with urgent
needs, not appointed in
advance
Include no-shows, lockdowns,
schedule change, etc.
Routine visits + Unscheduled
visits – visits failed/canceled
Number of Requests for
Medical Services received
Tab 4
Services/Procedures Provided
Total complete exams with treatment plans (1A-26)
Total preventive procedures
Dentist
Hygienist
“An examination by a licensed
dentist that includes a dental
history, exploration and
charting of teeth, examination
of the oral cavity and x-rays.”
Prophys, oral hygiene
education, plaque indices
Total treatment procedures
Periodontics
Restorative
Endodontics
Oral surgery (on site)
Prosthodontics
Prophylaxis
Gross scale/curettage
Deep scale/root plane
DRAFT - Monthly Medical Activity Report, DRAFT
Gross scale, scale/root plane,
probing
Fillings (temp.
or permanent),
crowns,
Completed
root canal
treatments,
pulpectomies,
pulpotomies
Alveoloplasty,
extractions,
biopsies, etc.
Appointments
for
impressions,
adjustments,
wax try-ins,
delivery, etc.
Cleaning & polishing to
include minor scaling
Removal of large deposits of
calculus (subgingival
primarily) to prepare patient
for further treatment
Scaling and root planing,
reported by quadrant, to
remove subgingival calculus
deposits
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