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Care of Patients Under Legal Custody (1.2.9)

Care of Patients Under Legal Custody (1.2.9) - Policies, Clinical, UW Health Clinical, Administrative, Legally Driven Care

1.2.9


UW HEALTH CLINICAL POLICY 1
Policy Title: Care of Patients Under Legal Custody
Policy Number: 1.2.9
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: December 6, 2016

I. PURPOSE

To address the care of patients under legal custody, including the ways to address forensic restraints that
are under the control of law enforcement agencies. Patients under legal custody include but are not limited
to inmates from the Wisconsin Department of Corrections, Federal Bureau of Prisons, and any police or
sheriff’s department.

II. POLICY ELEMENTS

A. Care of Patients Under Legal Custody.
i. UW Health will treat all patients under legal custody at the same level of care as all other patients,
providing an atmosphere supporting patient dignity and safety. Patients in legal custody will be
under supervision of law enforcement or corrections officers.
ii. Medical restraints or seclusion may be ordered by the physician related to the clinical care of the
individual, in accordance with UW Health clinical policy #2.4.2, Restraint and Seclusion. The
hospital will defer to the decisions of law enforcement officers concerning security restraints,
segregation and other disciplinary actions for forensic purposes. If the nursing staff or GME
(graduate medical education) staff have concerns that the patient's health care needs may be
compromised by these forensic actions, they shall notify the attending physician or the medical
director of the security unit. If the attending physician determines that the patient's health care
needs may be compromised by these forensic actions, the attending physician may request the
responsible law enforcement or corrections officer remove or modify the forensic restraint.
If the responsible law enforcement officer and attending physician do not reach agreement
concerning forensic restraints, then the medical director of the security unit or, when absent, his/her
physician designee, shall be contacted to discuss the matter with the responsible law enforcement
or corrections officer and/or agency. The final decision for forensic restraints remains with the
responsible law enforcement or corrections agency.
iii. Patients under custody will be designated as “SC” indicating protected status for that patient. In the
event that visitors or members of the public visit the hospital or call by telephone to contact patients
under legal custody, staff members should not acknowledge that an “SC” patient is present at the
hospital or clinics, or listed in the patient database. Staff should state, “We have no information on
this person. May I take your name and phone number in case there are any questions?” Staff
should then notify the UWHC Security Department regarding the caller’s name, telephone number,
and nature of the inquiry. UWHC Security will not call the person back; the information will be
forwarded to the appropriate correctional staff or law enforcement officer.
B. Discharge of Patients Under Legal Custody. The discharge of patients under legal custody will conform to
hospital policy on patient discharge and continuity of care. Patients under legal custody will remain in the
hospital only as long as is medically indicated. The hospital will not accommodate an increased length of
stay for non-medical reasons.
C. Responsibilities of the Medical Director of Security Unit. The Medical Director of the Security Unit will ensure
that the right of the patients under legal custody to the same level of care as other patients is protected. The
medical director may refer ethical issues and patient management issues to the Ethics Committee and/or the
VP, Quality & Patient Safety for discussion at the appropriate quality committee.

III. COORDINATION

Author: Legal Services Department; Medical Director of Security Unit; Director, Security Services
Senior Management Sponsor: SVP and General Counsel
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 21, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs



UW HEALTH CLINICAL POLICY 2
Policy Title: Care of Patients Under Legal Custody
Policy Number: 1.2.9

administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

IV. APPROVAL

Peter Newcomer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

V. REFERENCES

UW Health clinical policy #2.4.2, Restraint and Seclusion

VI. REVIEW DETAILS

Version: Revision
Next Revision Due: December 2019
Formerly Known as: Hospital Administrative policy #4.42