Health Record (PDF) pdf format of Form
rtf format of Form
The Health Care Record provides a concise and easy to use reference that can facilitate communication of relevant information and thereby improve the quality of health care. This format will standardize how that information is compiled and maintained, and replaces the current Personal Health Fact Sheet (or Health Care Fact Sheet) used at the ISP.

Every Individual served by us should have a Health Record:
Any individual who receives services from us and has an Individual Service Plan (ISP) should have a completed Health Care Record (HC-5). This should be entered electronically into the Department's HCSIS system, usually by the residential provider agency staff or by the person's service coordinator (or delegated area office staff).

A copy of the Health Care Record (HC-5) should be maintained in each individual's file with both their Service Coordinator and their Residential Provider, if applicable. If an individual has a change in Residential Provider, their Health Care Record must be updated at the time of transition and must accompany the individual to their new provider.

Events that trigger the update of the HCSIS electronic Health Care Record:

  • The approach of an ISP Review
  • Transfer of the individual from a intermediate care facility to a residential provider
  • A significant change in the individual's health

It is the responsibility of the Service Coordinator to ensure the record has been updated, especially in preparation for annual ISPs.

The 3-page format contains all the information necessary to provide a past and current history of an individual's health status. The Record will be utilized in the following manner:

"Portable Record" (Page 1):
This first page contains the most pertinent information a health care provider who is unfamiliar with the individual would need when conducting a routine, episodic or emergency visit. This should be considered the "portable" record that would provide a profile of the individual and could be copied and taken to a health care visit. When listing current medications, please refer to the sample Medication List below.

"Complete Record" (Pages 1, 2 and 3):

  • These pages in combination, replace the current Personal Health Fact Sheet (also known as the Health Care Fact Sheet) used for the annual ISP. The Complete Record must be updated at each annual ISP.
  • The Complete Health Care Record should be taken with an individual if they are going to the first visit with a new Primary Care Physician (PCP) or specialist. This complete version provides essential health history information for this new health care provider.


This information is provided by the Department of Developmental Services.