MANDATORY REPORTING OF CLINICAL CONDITIONS

Effective Date: 
Sun, 09/01/1996
Reviewed: 
Fri, 05/15/2015
Revised: 
Tue, 07/19/2016
Policy: 

In accordance with state law, including Penal Code Sec. 11160 et Seq., providers of health
services submit required reports of conditions to appropriate agencies.

  • A reportable communicable disease as defined by California and County Health Department reporting requirements, is reported to the Santa Cruz County Health Department.  A web link to to the Santa Cruz County Health Department is located in the EMR.  This link containis a list of all the mandatory reporting conditions, reporting criteria and reporting forms. 
  • Violent injuries including suspected sexual assault, domestic abuse, suspected domestic abuse,  elder abuse and child abuse are reported to Law Enforcement.  This also includes injuries resulting from assaults with or without a weapon. The Violent Injury Report form is located on the EMR along with the guidelines for reporting. 
  •  Animal bites are reported to County Animal Control for Rabies investigation.  The EMR references include the link to Animal Control and the guidelines for animal bite reporting.  The link also includes the algorithm for determining rabies risk and treatment requirements.
  • Pesticide-related illness are reported to the County Agricultural Commissioner through the Santa Cruz Health Department. 
  • Adverse vaccine reactions are reported using the Vaccine Adverse Event System.
  • Adverse drug reactions are voluntarily reported to MEDWATCH.
Procedure: 

Reportable Diseases

The health care provider who makes the diagnosis of a reportable condition is responsible for completing the appropriate form and submitting it to the designated agency.  

In the case of Sexually Transmitted Diseases the primary provider works with the patient and the County Health Department for appropriate partner notification.  Expedited partner treatment is offered.  

The list of conditions for which a report is required, up-to-date reporting instructions and appropriate forms for reporting are contained in the web link section of the EMR under Santa Cruz County Health Department.  This web link takes the provider directly to the  “Essential Public Health Reporting Guidelines for Santa Cruz County”.   Department of Health forms may be downloaded and printed, faxed or, in certain situations, completed and submitted electronically.  Specific instructions for each reportable condition are outlined at this web address.   

Some communicable diseases must be reported immediately, by phone, and require immediate community health management.  For conditions requiring immediate reporting a call should be placed by the treating clinician to the Health Department and to the Medical Director.  

The Medical Director and/or the Patient Care Coordinator work  under the advisement of the County Health Department to initiate any necessary infection disease control responses required.

Violent Injury

California state law requires that a health care provider make a mandatory police report for any person suffering from any wound or other physical injury inflicted upon the person where the injury is the result of assaultive or abusive conduct.  These mandatory report forms for Violent Injury Reporting are available in in the EMR Reference section  (also attached to this policy below). Violent Injury Report forms are used for reporting Sexual Assault as well as other forms of violent injury.  The primary provider for the patient is responsible for completing and submitting the Violent Injury Report form and for making the mandatory telephone report immediately or as soon as is practically possible.   Providers should call the UCSC Police.  UCSC police will assist the clinician to reach the appropriate police department if the injury occurred off campus.  

See Policy: Responding to Rape and Sexual Assault.
 

Animal Bites

The primary provider of the patient is responsible for completing animal bite reports.  The web link to the Santa Cruz County Health Department takes providers to the site where reporting requirements, forms, and guidelines for treatment are outlined.    The provider is responsible for following the County Health Department guidelines on animal bites. 

Pesticide Related Illnesses

The provider who diagnosis an illness potentially related to pesticide exposure is responsible for reporting this.  The web link to the Santa Cruz Health Department takes you to the Pesticide Report form and guidelines.  This report must be submitted within 24 hours of the diagnosis of suspected or known pesticide related illness.  The Santa Cruz Health Department will report this incident to the Commissioner of Agriculture for the county.

Vaccine Adverse Events

Any unexpected reaction to a vaccine should be reported using the national Vaccine Adverse Event Reporting System. The Vaccine Adverse Event Reporting System (VAERS) is a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). 

A link to the system is available in web references in the EMR (or on the Santa Cruz Health Department Web site).  The provider who identifies and documents the adverse event is responsible for completing the required report form. 

Adverse Drug Reactions

Adverse drug reactions are reported using the Adverse Drug Reaction System.  The Adverse Event Reporting System (AERS) is a computerized information database designed to support the FDA's post-marketing safety surveillance program for all approved drug and therapeutic biologic products. Reporting of adverse drug reactions is not mandatory but is strongly encouraged to assist the FDA in its mission of post marketing safety.  The clinician who identifies an adverse drug reaction is responsible for submitting this report.

Patient Notification and Documentation

If a patient has a condition which requires making a formal report to one of the agencies above, they are informed of this and they are informed of what they may expect in terms of follow up to this report or contact from the agency.

Every effort should be made to help the patient understand the public health aspects of the condition to facilitate cooperation with investigation and control.  

In the case of Violent Injury, the patient is to be informed that a report is submitted and police may contact them for more information.   Report forms  include the opportunity to make note of patients who do not wish to be contacted by police.   The clinician should make sure the patient understands this option and note it on the form as appropriate.

The primary provider documents that a report has been submitted.  A copy of the report is scanned into the EMR.  If a report was submitted electronically  it is still necessary to print and scan a copy for the EMR.  

Key Points: 

 

  • Mandatory reporting requirements are met by health center staff according to state and federal requirements.
  • Web links  and Internal References in the EMR facilitate reporting by linking providers to the appropriate references for reporting including guidelines, forms, and important phone numbers. 
  • Clinician identifying the condition or situation requiring reporting is responsible for carrying out the mandated report and noting this in the Medical Record. A copy of the report is scanned into the electronic medical record in scanned documents. Reports of violent injury, including sexual assault, are made by telephone with a follow up written report.
  • The Medical Director and the Patient Care Coordinator are responsible for working with appropriate agencies to address any public health activities which may need to occur on campus as a result of such conditions.  
  • Patients are informed that mandatory reporting occurs. Every effort is made to address and maintain confidentiality while at the same time meeting public health and safety imperatives.
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