One of the primary responsibilities of a HWM is to ensure that student records reflect all the health services provided to the Job Corps student.  This includes not only the examinations, findings, immunizations, laboratory studies and results, but also the health teaching provided to the student by HWC staff.  Since this becomes part of a student's permanent Job Corps record, the HWM should ensure that it is complete and audited regularly.  This is a quality assurance tool to identify opportunities for improvement and reflects the integrity of the wellness program on your center.  Job Corps charting guidelines are available at Essentials of Job Corps Health & Wellness Charting—Medical, Oral Health, Mental Health and TEAP Charting.

Every once in a while we need to review our foundations.  You will probably read this article and think ‘I already knew that’.  After you have that thought, take a step back to figure out if you are doing all of these items consistently.  This may be a good time to audit your folders.

• Consistency is the key.  Each folder should be in the same format.
• Limit items on the cover of the folder.  It is fine to have the student’s name, and possibly, the student ID number and allergy information.
• All students with chronic health problems should have a chronic care plan or treatment plan with clearly documented follow-up to ensure continuity of care.  Any education provided should be documented.
• Be sure to include a synopsis regarding the student's health on entry and any complaints and referrals done at that time.
• The folder should include copies of all off-center treatment or referrals, all lab tests and follow-up lab tests, and all required cursory vital signs.
• Document notes on teaching employability, independence, and self-care.
• All notes and copies of the eye prescription should be in the folder.
• The complete HIPAA Notice must be filed in the chart.  All case-management notes and follow-up documents should be included, especially if the student is HIV positive.
• All folders are confidential, and PII needs to be protected at all times.  Folders need to be locked in a file cabinet. The health and wellness center needs to be double-locked when staff is absent.  No files should be left where anyone could potentially have access.
• Before you send a chart to the National Office, look through it for consistency and completeness.  All charts should be sent to Carol Abnathy at:
  
  DOL/Office of Job Corps
  Room N-4507
  200 Constitution Avenue, NW
  Washington, D.C. 20210