medical records must be retained by the prison service for as long as specifed
in the relevant national law.
Prison doctors have the duty to examine and document all signs of physi‑
cal, psychological and sexual violence. During the medical examination on
admission a prisoner may report police violence. It is therefore important
to present any such evidence to the authorities. If the prisoner is reluctant to
give consent for this, the doctor must seek ways of ensuring that the victim’s
identity is not revealed to the ofender. The Istanbul Protocol49 provides guid‑
ance on documentation that is valid both professionally and legally, and on
non‑traumatic methods of examination in cases of violence and ill‑treatment.
Access to medical fles and other medical information
Prisoners should be provided with all relevant information – if necessary in
the form of a medical report – on their condition, their course of treatment
and the medication prescribed for them. Preferably, they should have the right
to consult the contents of their medical fles, unless this is not advisable for
therapeutic reasons. They should also be allowed to request the information
to be communicated to their families and lawyers or to an outside doctor.
Statistical (non‑patient‑related) medical records
In line with national law and in co‑operation with the community health author‑
ities, prison doctors should keep statistical records of all aspects of health‑care
services performed in the prison, in particular the number of consultations and
prevalence of pathologies, measured by the number of diagnoses according
to the International Classifcation for Diseases (ICD) code, including specifc
records of notifable diseases, such as tuberculosis – using the standardised
case defnitions and treatment categories of the World Health Organization
(WHO) – dysentery, hepatitis and HIV. Such statistics are processed in a much
easier way through electronic medical record systems, providing support for
budgeting and for the implementation and evaluation of health‑promotion
and prevention programmes.
As mentioned above, prison doctors should keep statistics of all injuries
and causes of injury (inter‑prisoner violence and ill‑treatment) and should
regularly report the data to the prison authorities. Systematic statistics of
violence facilitate assessment of the situation and evaluation of preventive
49. CPT Standards 2002 (rev. 2011).
Medical ethics in prison Page 23
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