Military reference books and manuals (2009-2023, Volume 6) - page 44
Chapter 3
detainee through the medical facilities. Once an ISN is assigned to a detainee, all further documentation, to
include medical records, will use only the ISN (no other numbering system will be used). Additionally,
previously generated documents using the capture tag number should be annotated with the ISN. The DRS
cross-references the ISN and the capture tag number for administrative purposes.
SECTION III — AT THE INTERNMENT FACILITY
MEDICAL SCREENING
3-59. The medical examination of detainees is an important process used to protect the detainee population
from preventable illnesses or injuries through early detection of medical problems. The medical
examination of detainees is for medical purposes only. As with any medical procedure, it is important to
safeguard the dignity and privacy of the individual while also maintaining an environment of maximum
safety and security for detainees, medical staff, and the staff of the TIF. For information on medical
inprocessing screening tools refer to Appendix C.
INTERNMENT SERIAL NUMBER
3-60. Detainees are provided an ISN when being inprocessed to the TIF. The TIF is the only location
where this number will be assigned. To identify detainees prior to the issuance of the ISN, the capture tag
number (DD Form 2745) is used on all documentation concerning the detainee. Once the ISN is issued,
existing records are updated.
3-61. Detainees require an identification number in order to begin medical processing, so that tests and
medications can be ordered as required. This particular aspect is governed by the MP unit in charge of
inprocessing. Any computer malfunctions or systems problems can affect how quickly a detainee is ready
for medical screening. Of course, at any time if a detainee requires urgent or emergent care, capture tag
numbers will suffice until the proper processing can be accomplished.
Note. No detainee will be refused care because an ISN cannot be provided up front.
PRIORITY OF PROCESSING
3-62. Detainees with identified medical conditions that require daily medication should be front-loaded for
processing. This includes detainees with diabetes, high blood pressure (BP) or heart disease, asthma, and
seizures. By front-loading these detainees, potential medical problems can be identified early-on and
prevented and medications can be quickly restarted.
AVAILABILITY OF MEDICAL DOCUMENTATION
3-63. All medical documentation and medications from screening examinations or treatment at prior
locations, such as the DCP or DHA, should be available for review and inclusion in the medical record.
All documentation conducted on DD Form 1380, SF 600 (Medical Record-Chronological Record of
Medical Care), SF 558 (Medical Record-Emergency Care and Treatment [Patient]), or other medical
forms completed by the Role 1 or Role 2 MTF providing area support will accompany the detainee
throughout the roles of health care. Many times, these records contain important information regarding the
detainee’s presentation and health status immediately after capture. Each entry helps to provide a
chronological picture of the detainee’s medical condition over time during the time of his initial detention.
In addition, the MTF providing area support to the capturing unit may have taken useful photographs of
injuries that are healing or may already be healed by the time the detainee arrives at the TIF.
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Medical Guidelines for Detainee Operations
WORKLOAD VARIANCE
3-64. Workload can vary widely based upon mission, enemy, terrain and weather, troops and support
available, time available, and civil considerations (METT-TC). The staffing required to conduct medical
inprocessing at the TIF must be adequate to ensure that detainees are provided with timely medical
examinations and that all administrative requirements for the initiation of individual medical records and
weight registries are successfully completed. Medical screening includes completing a medical history (to
include immunizations), physical and dental examinations, and BH assessments. Diagnostic testing (such
as a urinalysis) and administering immunizations are governed by command policy and medical necessity.
In addition to the health care provider, sufficient staff is required to accomplish ancillary and
administrative support functions. The clinical standing operating procedure
(CSOP) should address
procedures for obtaining augmentation of these resources, if required.
STANDARDIZED FORMS
3-65. Preprinted physical examination, BH, and dental screening forms can streamline initial inprocessing.
Past medical history should focus on past and current communicable diseases (TB, HIV, and STD), major
health problems (asthma, cancer, diabetes, epilepsy, hemophilia, heart disease, and hypertension), allergy
to foods, medications, or insects, past surgeries, recent or current medication use, and social habits such as
alcohol and tobacco use. Translating routine past medical history questions into the local language can
accelerate the preprovider contact, as long as the detainee is able to read. Refer to Appendix C for sample
preprint formats for the SF 600 for detainee physical screening and quality assurance screen of a detainee’s
medical record.
LINGUIST SUPPORT
3-66. Multiple linguists are necessary to keep each section of medical processing moving smoothly.
Because of the nuances in medicine, an accurate medical examination is not possible without translator
assistance. Ideally, one translator is necessary for each of the following sections: BH, roving, screening,
and per each provider. It is difficult for two providers to share one translator and nearly impossible when
there are three providers performing evaluations. As a preventive measure to preclude intelligence
gathering, translators should be rotated. This prevents the development of detainee familiarly that can
result in the flow of nonmedical information.
3-67. For additional information on linguist support refer to paragraphs 3-11 through 3-20 and Appendix G.
HEALTH STATUS INDICATORS
3-68. Baseline vital signs, including BP, heart rate, height, weight, and body mass index (BMI), help to
determine a detainee’s initial overall health status. As with all patients, these values are useful for
comparison when a detainee presents at some future time with complaints. Weight and BMI are essential
to evaluate a detainee’s initial nutritional status, as well as his ongoing physical condition during
confinement. A BMI less than 18.5 should prompt evaluation by a nutritionist. In addition, AR 190-8
requires that detainees have monthly weights registered on Department of the Army (DA) Form 2664-R
(Weight Register) (Figure 3-1) and kept on file. Based upon tracking requirements set by the CDO and
DOMD, this information may be obtained by either medical or MP personnel, and tracked electronically or
in a separate, hard-copy format.
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Chapter 3
Figure 3-1. Sample Department of the Army Form 2664-R, Weight Register
REGULATORY SCREENING
3-69. Army Regulation 190-8 specifies that a medical officer will examine each civilian internee (CI) upon
arrival at a facility and monthly thereafter. The CI will not be admitted into the general population until
medical fitness is determined. These examinations will detect vermin infestation and communicable
diseases especially TB, malaria, and STDs. They will also determine the state of health, nutrition, and
cleanliness of each CI. During these examinations, each CI will be weighed, and the weight will be
recorded on DA Form 2664-R.
3-70. For children up to 14 years of age, a tuberculin skin test (TST) will be administered. No chest x-ray
is necessary if the TST is negative. The local medical officer will establish guidance for subsequent tests
based on the TB experience of the population. Routine annual tuberculin testing of children is not
warranted unless there is clear-cut evidence of high risk. Any CI with results suggestive of active disease
must be started promptly on quadruple drug therapy and be kept in isolation until symptoms have resolved
and multidrug therapy has been underway for two to four weeks. Current guidance from the Centers for
Disease Control and Prevention (CDC), as well as the World Health Organization (WHO), recommends
quadruple therapy for two months. This entails a four-drug regimen of isoniazid (INH), rifampin (RIF),
pyrazinamide (PZA), and ethambutol (EMB) or streptomycin (SM) until the drug susceptibility results are
known. If the drugs are given daily at the start of therapy and susceptibility results show no drug
resistance, EMB or SM can be discontinued and the other drugs continued until PZA has been given for 2
months. Isoniazid and RIF should then be continued for another 4 months, including at least 3 months of
therapy after the culture has converted to negative.
MEDICAL RECORD GENERATION
3-71. The initial care provided to detainees at Role 1 may be documented on DD 1380 but once detainees
are evacuated to the role of care with the appropriate medical record folder (DA Form 3444-series
[Alphabetical and Terminal Digit File for Treatment Record] or DA Form 8005-series [Outpatient Medical
Record [OMR]), the color coded medical record containing the required demographic information will be
initiated.
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Medical Guidelines for Detainee Operations
3-72. A medical record will be generated after the completion of the medical screening process. The
physical examination, BH, and dental screening forms should be included, as well as a detainee dossier for
identification purposes and a DD Form 2766 (Adult Preventive and Chronic Care Flowsheet) or DD Form
2882 (Pediatric and Adolescent Preventive and Chronic Care Flowsheet), as appropriate. Consider the
inclusion of a quality assurance form that tracks the completion of all aspects of the medical screen and any
detainee limitations on activity, diet, travel, or facility placement. This form should be signed by the
examining provider at the end of the encounter and reviewed by the inprocessing NCOIC for completeness.
3-73. If the detainee was provided medical care at temporary detention locations, the FMC becomes a part
of the detainee medical record.
DISPOSITION OF MEDICAL RECORDS
3-74. Detainee medical records will be processed for disposition as required by the following regulations
and guidance:
AR 40-66.
AR 25-400-2.
Quick Reference Guide to Documenting Operations for Deployed Units of the Army (available
3-75. Detainee inpatient medical records and OMRs will be dispositioned to the following locations:
Inpatient records and the extended ambulatory record will be dispositioned to the following
record holding facility:
Director
Detainee Administration Systems and Biostatistics Activity
ATTN: MCHS-ISD
1216 Stanley Road, Building 126, Suite 25
Fort Sam Houston, Texas 78234-5053
Outpatient records will be dispositioned upon release or final disposition of the detainee from
detention. These outpatient records will be forwarded to the following record holding facility:
Washington National Record Center
4205 Suitland Road
Suitland, Maryland 20746-8001
RELEASE OF INFORMATION
3-76. The Health Insurance Portability and Accountability Act does not apply to the medical records of
detainees and EPWs. Given that the Geneva Conventions require the military to provide the same standard
of care to detainees and EPWs as US Forces, detainee/EPW medical records should be initiated and
maintained at the same standard. The procedures outlined in AR 40-66 regarding the release of medical
information for official purposes should be followed for detainee/EPW medical records.
3-77. Due to responsibilities of the TIF chain of command regarding the care and treatment of
detainees/EPWs, they are entitled to some medical information. For example, detainees suspected of
having infectious diseases such as TB should be separated from other detainees/EPWs. Releasable medical
information on detainees and EPWs includes that which is necessary to supervise the general state of
health, nutrition, and cleanliness of the security force, detainees, and EPWs and to detect contagious
diseases. The information released should be used to provide health care, to ensure the health and safety of
detainees and EPWs, to ensure the health and safety of the personnel operating or working in the TIF, to
ensure law enforcement on the premises, and to ensure the administration and maintenance of the safety,
security, and good order of the facility.
3-78. Detainees should be entitled to copies of their medical records upon release from the TIF. Copies of
medical documentation provided to released detainees will have all US military unit designation, health
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Chapter 3
care provider, and other medical support personnel information (for example, name or provider number)
redacted (removed or obliterated).
DOCUMENTATION OF EXISTING MEDICAL CONDITIONS OR
INJURIES
SCARS, MARKS, AND TATTOOS
3-79. All identifying scars, marks, and tattoos should be clearly documented on a body diagram. Many
detainees will become curious or even fearful when asked to display all of his tattoos. Clarify to the
detainee that this documentation serves for identification purposes only. However, some tattoos have
significance other than body art, which is why these should be carefully documented for future reference.
DETAILED DOCUMENTATION OF INJURIES
3-80. Areas of injury must be clearly documented and described in detail during the initial inprocessing
physical. This process is important for continuing wound care and notification of the wound care team.
Wound care is essential for all new detainees requiring ongoing treatment. Consider admission for any
detainees with large or infected wounds.
IDENTIFICATION OF EXISTING MEDICAL CONDITIONS
3-81. Medical conditions should be identified in the preprovider screening and confirmed by the provider
prior to examination. Occasionally, detainees will believe that they have a certain illness or condition
based upon their current or past symptoms. It is essential for the provider to verify all affirmative
responses so that ongoing medical conditions can be treated and questionable conditions and medical
concerns can be clarified by the provider.
PRESCRIPTIONS AND INITIAL TREATMENT
3-82. Provide prescriptions, consults, and initial treatment as needed. Some detainees will know their
prior medications by name and efforts should be made to restart these same medications, if indicated. Most
times however, detainees will only know that they were taking a pill for their condition. Be sure not to
overmedicate; if questions remain about a diagnosis, encourage follow-up in the facility prior to starting
treatment.
SEGREGATION OF MEDICALLY CHALLENGED DETAINEES
3-83. Consider segregating detainees with medical conditions, wounds, or physical impairments for ease of
treatment. Having these detainees in a centralized facility area improves treatment compliance and follow-up.
MEDICAL PHOTOGRAPHY
3-84. Army Regulation 190-8 prohibits the photographing, filming, or videotaping of individual detainees
except for facility administration and intelligence/CI purposes. Health care personnel are permitted to
photograph detainees to document preexisting conditions, injuries, and wounds. The individual’s identity
should be clearly visible. These photographs are invaluable if a claim of unnecessary surgery or
amputation is made. Any detainee who requires amputation or major debridement of tissue should be
photographed. Once taken, these photographs are maintained as part of the individual’s medical record.
3-85. Consider the use of photography for documentation and treatment purposes. Detainees may arrive at
the TIF with photographs of wounds or injuries taken by health care personnel at the DCP or DHA. These
are helpful to monitor the resolution or progression of injuries and are filed in the detainee’s individual
medical record.
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Medical Guidelines for Detainee Operations
3-86. Medical photography can also be used for medical diagnosis and treatment and used for the
management of a number of medical conditions. Contact the Office of The Surgeon General (OTSG)
Clinical Consultant to obtain current guidance for submission of teleconsultations at e-mail
derm.consult@us.army.mil. This consult capability is used only in a deployed environment. Generally a
teleconsultation consists with a brief summary that includes presentation and symptoms, current medical
problems, prior treatments and response to treatment and family history of similar conditions, along with
one or more clear photographs of the area in question. Most often, an e-mail response will arrive in less
than twelve hours and will include a differential diagnosis and potential treatment plans.
3-87. The Army teleconsultation program may be used to assist with diagnosis and the management of
medical conditions for detainees. A number of specialties participate in this program providing reach-back
in a number of areas including burn-trauma, cardiology, dermatology, infectious diseases, nephrology,
PVNTMED, occupational medicine, and toxicology. Health care providers may visit the Deployment
Health Clinical Center Web site (http://www.pdhealth.mil ) for a complete list of available consultation
programs for deployed providers.
COMPLETION OF MEDICAL INPROCESSING
3-88. Necessary medical treatment and wound care should be addressed at the completion of medical
processing. It is essential to expose and visualize all wounds to document the size and current condition of
the wound. On most detainees, wound care for existing injuries will be adequate; however, on occasion,
wounds can be infected or even necrotic upon evaluation. Although medical inprocessing is not sick call,
detainees may not have received health care for several days and may require some sort of treatment for
existing injuries or medical conditions. This generally applies to elevated BP and blood sugar. Detainees
will also complain of headache, muscle and joint aches, heartburn, or upper respiratory infections, and
these problems can usually be treated adequately with over-the-counter (OTC) medications. Detainees not
fit for internment life should be admitted for further assessment and treatment.
ALLEGATIONS OF ABUSE OR MISTREATMENT
3-89. Allegations of abuse or mistreatment, by either multinational or HN forces, should be referred to
CID with a copy of the provider’s physical examination and any applicable laboratory or radiology studies.
Most times, the investigator will need to interview the provider to obtain any additional information.
Allegations of abuse by multinational forces are fully investigated, but allegations of abuse by HN forces
are generally for information collection only and that information is forwarded on to HN authorities. For
additional information refer to paragraphs 1-44 through 1-60.
MONITORING
MEDICAL SURVEILLANCE
3-90. Medical surveillance is the ongoing, systematic collection of medical data that is essential to the
evaluation, planning, and implementation of public health practice and prevention. In particular, it
includes medical data related to individual patient encounters and the use of that data in the calculation of
disease and nonbattle injury (DNBI) rates for a defined population for the primary purposes of prevention
and control of health and safety hazards. During medical surveillance, PVNTMED assets monitor the
detainee population in order to identify and reduce incidents and counter health threats. The senior
PVNTMED officer in the task force is required to establish a medical surveillance program for detainees.
Information that is collected is maintained on a database that can be made available to the command,
international inspectors, and PVNTMED personnel to track disease trends, as required.
3-91. Medical surveillance identifies the population at risk, identifies potential and actual exposures,
determines protective measures, and assesses an individual’s health. The final link is the application of this
data to prevention and control.
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Chapter 3
3-92. The data collected from this assessment forms the health status of detainees. It identifies the
endemic and epidemic diseases present in the detainee population; provides the facility commander with
pertinent information on which to monitor changes in the detainee health status; and provides the basis to
perform health interventions, as necessary.
Medical surveillance data is used to monitor the
implementation and effectiveness of PMM and the maintenance of field sanitation and hygiene practices.
For example, an increase of acute diarrheal disease within a subpopulation of the detainees may necessitate
an epidemiological investigation to determine the cause of the outbreak and to ensure the spread of disease
is contained. Once the source of the disease outbreak is determined, PMM can be devised and
implemented to ensure there is not a recurrence.
3-93. Health risk communications and instructions can be developed and disseminated to the detainee
population to promote an understanding of the health threat faced by the facility and to enhance
compliance with required PMM, field sanitation requirements, and personal hygiene standards to counter
the threat.
MONTHLY WEIGHT
3-94. To ensure the continued health of detainees, international law requires that each detainee be screened
monthly by health care personnel. During this screening, the detainees weight is recorded on DA Form
2664-R which provides a concise, chronological weight history for the detainee. Significant fluctuations in
weight can signal an underlying medical condition or can indicate that the detainee diet is not meeting his
nutritional requirements. The cause of any significant fluctuations must be investigated by health care
personnel. Detainees with significant weight fluctuations are given a more thorough physical to determine
if an underlying medical condition exists or if a disease process is present. If the physical examination
does not identify the underlying cause, a thorough evaluation of the individual’s diet and work schedule
should be undertaken. Findings and recommendations for adjustment of diet should be made to the facility
commander. Cumulative data on weight fluctuations should be included in the medical surveillance
activities conducted at the facility to ensure trends are identified as rapidly as possible and corrective
measures implemented.
3-95. When conducting monthly weigh-ins, health care personnel should also be alert to the signs and
symptoms of communicable diseases, louse infestations, hydration status, and other indicators of health
status. If a detainee has any signs of unexplained physical injuries (such as burns, fractures, severe sprains,
or bruises), health care personnel should ask the detainee about the cause of the injury. However, health
care personnel do not investigate allegations or suspected incidents of abuse. Any cases of suspected
abuse, both by TIF personnel or other detainees, should be documented and immediately reported to the
TIF commander, the supporting CID, and the DOMD.
MEDICAL CONDITIONS
3-96. Detainees requiring periodic evaluations (for example, detainees with diabetes or TB) should be
tracked to maintain compliance with laboratory testing standards, among other pertinent issues. Given the
potential for rapid movement of detainees between compounds and/or between internment facilities, it is
essential that these detainees are not lost to follow-up.
SICK CALL
3-97. Gather and chart DNBI data from the daily disposition log (Figure 3-2) to quickly address emerging
trends or problems. This is most easily accomplished by documenting the ISN, body system (cardiac,
respiratory, and so forth) and chief complaint on a matrix.
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FMI 4-02.46
8 November 2007
Medical Guidelines for Detainee Operations
DAILY DISPOSITION LOG
NAME
ISN
COMPOUND
INJURY OR ILLNESS
DISPOSITION
Doe, John
12345
East
Dehydration
RTC
Smith, Matt
23456
North
FUO
RTC
Jones, Al
34567
East
TB
Evacuate
Figure 3-2. Sample daily disposition log
MONITORING DETAINEE IN SEGREGATION
3-98. Detainees maintained in segregation will be monitored daily to assure health and well-being and to
address current medical complaints. By protocol, a licensed independent provider (physician, physician
assistant [PA], or nurse practitioner) must screen and sign off on each detainee; however, local guidance
may allow for a nurse to perform this screening as well. Given the segregation status of these detainees, it
is usually more expedient for the provider to use this requirement as a sick-call opportunity as well. A
translator is helpful, but not essential in this situation and either an English-speaking detainee or a hired
linguist, if available, is appropriate.
MONITORING MEDICATIONS
3-99. Monitor medication compliance in each compound by detainee to optimize treatment. A good way
to accomplish this goal is by creating a spreadsheet (Figure 3-3) that lists each ISN, drug allergies, the
medication, route and dosage, start date, number of refills, and whether the medication was
“A”
(administered), “R” (refused), or “NS” (no-show). No-shows can be further broken down to provide a
reason (such as “FV” [family visit]), if desired. By tracking in this manner, medication compliance can be
easily monitored and reported.
LIB1
1
150131
None
Glucotrol 5 mg
4 tab b.i.d.
30 Apr 05
2
A
A
A
A
LIB1
1
150131
None
Metformin 500 mg
2 tab b.i.d.
27 Apr 05
2
A
A
A
A
LIB1
1
150131
None
Aspirin 81 mg
1 tab q.d.
27 Apr 05
4
A
A
LIB1
2
151996
None
Norvasc 10 mg
1 tab q.d.
15 Apr 05
2
A
A
LIB1
2
151996
None
Atenolol 50 mg
1 tab b.i.d.
21 Apr 05
2
A
A
A
A
LIB1
3
153722
None
Ibuprofen 800 mg
1 tab b.i.d.
03 May 05
2
FV
A
A
A
LIB1
4
154097
None
Gabapentin 100 mg
2 tab q.d. pm
02 May 05
8
R
A
LIB1
4
154097
None
Metformin 850 mg
1 tab b.i.d.
28 Apr 05
0
A
A
A
A
LIB1
4
154097
None
Cozar 50 mg
1 tab q.d.
09 Apr 05
0
A
A
LIB1
4
154097
None
Flomax 0.4 mg
1 tab q.d.
21 Apr 05
2
A
A
LIB1
4
154097
None
Flonase spray
2 sprays q.d.
09 Apr 05
2
A
A
Figure 3-3. Example medication tracking matrix
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Chapter 3
3-100. All medications to be administered to detainees must be dispensed by health care personnel.
Depending upon the detainee’s medical condition, health care providers, when possible, should prescribe
medications which can be dispensed on a once or twice a day basis. To ensure the safety of detainees,
medications are dispensed in unit doses by health care personnel. Health care personnel must verify the
identity of the detainee (usually a wristband), obtain their signature on the medication issue register (Figure
3-4) and watch/verify that the detainee takes the prescribed dose. When dispensing oral medications, the
detainee’s hands and mouth should be inspected to ensure the detainee swallowed the medication and is not
attempting to hoard the medications for later use. The medication issue registry is primarily used to
accurately track the medications each detainee takes, as well as to prevent medication duplications and
potentially dangerous interactions. A local form can be developed to document the dosing schedule and
the receipt and administration of the medication to detainee. This register requires the detainee to sign for
his medications and when he has completed his course of treatment, can be filed in his medical record.
Detainee Name
ISN
Domicile Location
Physician
Doe, John
123456
Block C, Tier 1
LTC Smith
Type of Medication
Dosage
Ibuprofen
200 mg
Prescription Label
Instructions
Date 01/01/05
Take 2 tablets, 2 times a day
Detainee John Doe was notified on the 1 January 2005 by guard SGT C. Brown
that the medication had arrived and is to be taken as prescribed.
SAMPLE
MEDICATION ISSUE REGISTER
DATE
TIME
DETAINEE
PILL
ADMINISTERED
INVENTORIED
SIGNATURE
COUNT
BY
BY
(health care provider
signature)
01/01/0
1700
------------------------------
20
-------------------------
5
(health care
provider signature)
01/01/0
1715
(detainee signature)
2 -- 18
--------------------------
5
(health care provider
signature)
01/01/0
2045
------------------------------
18
-------------------------
5
Figure 3-4. Sample medication issue register
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Medical Guidelines for Detainee Operations
ROUTINE MEDICAL CARE
DAILY CONTACT
3-101. Regulatory guidance requires that detainees must be offered the opportunity for daily medical
contact. Medication administration and emergency medical care are considered medical contact.
3-102. Different levels of sick call (full or modified) can assist with compliance. Sick call may be offered
in stages. For example, Stage 1 sick call involves care through the wire with or without offering
medication. Health care specialists may also offer OTC medications for simple problems, such as
headache, upset stomach, or minor musculoskeletal pain. Blood draws and intravenous
(IV)
fluids/medications can be completed at the wire as well, based upon the provider’s guidance and the health
care specialist’s confidence level. Stage 2 sick call involves evaluation by a licensed provider at the wire
and the detainee may be removed from the wire, if necessary, for a more complete examination. Stage 3
sick call requires movement of the detainee into the treatment tent for more in-depth evaluation and
treatments, as needed. These treatments can involve nebulizer treatments, cardiac rhythm strips, IV fluids,
and minor procedures. Finally, Stage 4 sick call requires transport to the hospital facility for urgent
evaluation and treatment.
SICK CALL WORKLOAD MODELING
3-103. Evaluation of at least 10 percent of the facility population per sick call is appropriate, based upon
staffing and documentation requirements. This strategy assures that a baseline number of detainees are
receiving medical care on a regular basis. Standard documentation guidelines should apply, meaning that
either a short or expanded SF 600 be completed for each encounter, depending upon the problem’s
complexity. In addition, the medical commander may opt to set a schedule based upon the common
complaints within the facility. For example, each sick call might start with a dedicated number of acute
illness appointments, followed by time on a dedicated day for specific specialty care such as optometry,
cardiac, diabetes, or musculoskeletal problems that are recurrent or acute.
PROVIDERS
3-104. Unlicensed personnel may perform sick call under the supervision of a licensed provider. This
includes Army health care specialists, United States Air Forces (USAF) medics, United States Navy (USN)
medical corpsmen and independent duty medical technicians/corpsmen. As an alternative, enlist the
support of nursing personnel to further triage and assess detainees as they present. A licensed provider
(physician) should assist on-site in the evaluation of detainees that are more difficult, either at the time of
the initial presentation or at a dedicated later timeframe. Each SF
600 should be reviewed and
countersigned by a licensed provider.
OVER-THE-COUNTER MEDICATIONS
3-105. All prescription medications must be ordered by a licensed provider; however, if compound
dispensary stock allows, the provider may directly dispense common medications out of the on-site stock.
Over-the-counter medications do not require approval prior to dispensing, however unlicensed providers
must be fully trained by either a licensed provider or licensed pharmacy staff regarding each medication, its
indications, and any potential side effects.
SICK CALL PRACTICES
3-106. Timeframes are established for sick call and distribution of medication to avoid abuse of the
medical system. Medication pass (distribution) should not extend past a two-hour timeframe, unless there
are extreme circumstances; however, most compounds can complete medication distribution within one
hour. Detainees must present for any sort of medical encounter with his identification band on hand. This
aids in confirmation of that detainee’s identity. In addition, the detainee must have water on hand for
medication consumption. Absence of either the identification band or water can cause major delays in
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Chapter 3
medication distribution as well as sick call. Allow a certain amount of time for sick call. Usually this
should not exceed three hours, especially if there is no overhead cover for the personnel performing sick
call. Setting limits permits the health care specialist or provider to command the situation, in contrast to
allowing the detainee to dominate the encounter. Consider using a sign-up sheet, distributed at night, for
the next day’s sick call “appointments.” Experience shows that an “open-access” system, now popular in
clinics nationwide, can be cumbersome and overwhelming. Allow a standard number of sick call slots and
plan for acute illness visits as well.
ASSISTANCE WITH MEDICAL COMPLIANCE
3-107. Enlist the help of the facility hierarchy and the MPs to attain the fullest compliance with
medication distribution and sick call. Upon arrival of a new group of cadre personnel, whether medical or
MP, the health care personnel and the guards for each compound should discuss such issues as medication
noncompliance and its consequences, detainee good order and discipline during medication pass and sick
call, and MP overwatch during detainee interactions. Generally, each compound has a “chief” and a chain
of command that wields a great deal of power among the detainees within that compound. These men can
be very influential and health care personnel should capitalize on their authority to ensure the mission’s
success. If feasible, consider allowing the compound chief to designate which detainees should be seen for
sick call, ultimately making him responsible for the success of his compound’s medication pass and sick
call and reproducing the hierarchy commonly seen in the local population.
CONSUMPTION OF MEDICATIONS AND COMPLIANCE
3-108. Verify consumption of medication to avoid cheeking, which can lead to hoarding, bartering, and
overdose. A detainee must present for medication pass with his identification band to assure that the
medication is dispensed to the proper detainee. He must also have water on hand to accompany his
medication dose. Consider requiring the detainee to also roll up his sleeves, so that he cannot hide his
medication in them. As the detainee takes his medication, he must demonstrate a swallowing action and
open his mouth after swallowing to verify consumption of the medication, moving his tongue around to
show that the medication is no longer in his mouth. He must also show his hands, front and back, with
fingers spread widely, to verify that he does not have the medication in his hands. Many times during a
shake-down, MPs will find medications in a detainee’s possession and, upon investigation, medical records
will not show that the detainee has a prescription for that medication. Unfortunately, this problem can lead
to adverse events, like allergic drug reactions, episodes of low BP or blood sugar, and even death.
3-109. Detainees may refuse to take medication unless this refusal represents an immediate hazard to their
health (such as refusal of insulin in an insulin-dependent diabetic). If a detainee fails to present for
medication distribution for three days and has been counseled by an independent licensed health care
provider, he may have the prescription removed from the distribution database. A detainee refusal of
medication must be documented in his medical record.
3-110. Refer to paragraph 3-100 for information on monitoring and tracking medication administration.
FOLLOW UP FOR DETAINEE TRANSFERS AND COMPLIANCE
3-111. Follow up on all intercompound or interfacility detainee transfers to maintain compliance with
medication. Normally, there is a constant flow of incoming new detainees corresponding with ongoing
operations throughout the AO. When the operational tempo is high, detainee movement tends to increase,
usually within the facility as well as between facilities. A high-quality tracking mechanism vastly
improves the ability of health care personnel to move medications with the detainees. In addition, open
lines of communication within the medical staff, as well as with the MP Operations Staff Officer, US Army
(S3) is essential to knowing where detainees are and where they will be moving at any given time. It is
common for medications to lag a day behind the detainee during transfers within the facility. During
interfacility transfers, it is also extremely helpful to use e-mail communications with the accepting facility
so that the health care personnel at the new facility are aware of the incoming medical detainees, their
diagnoses, and their medications. e-mail serves two important roles by providing a hard copy of the
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Medical Guidelines for Detainee Operations
information for the accepting provider and by serving as documentation of transfer notification for
medicolegal purposes, as well as common courtesy.
MEDICAL EVACUATION
3-112. When a detainee requires evacuation to a higher role of care, the TIF control center is notified and
arrangements are made for medical evacuation support. Translator support is required to facilitate EMT en
route to the hospital. Translator support may be provided by radio transmission or a translator may be
onboard the ambulance. The health care personnel onboard the ambulance will remain in radio contact
with the health care provider at the Role 3 hospital throughout the evacuation. A TIF facility guard also
accompanies the detainee throughout the evacuation. After treatment, the detainee is returned to the TIF
by ambulance, if appropriate. If the detainee is to be admitted to the Role 3 hospital, the ambulance crew
returns the TIF facility guard to his duty station. The evacuation and medical treatment received is
documented in the detainee’s health record and on the ambulance run sheet.
3-113. When a detainee returns to the TIF from the hospital, he is examined by the TIF facility physician.
The hospital provides clear and concise instructions for follow-on care to be given at the TIF. Medical
equipment and supplies normally not available at the TIF but required for the continued care of the
detainee are provided by the hospital. The TIF physician coordinates with the hospital any appointments
required for continued care.
FOLLOW UP FOR DETAINEE RETURNING FROM HOSPITAL FACILITIES
3-114. All detainees returning through medical channels should be evaluated in the ER before transfer to
the processing center to determine a need for further hospitalization. This process can be cumbersome at
times, but it nearly eliminates the possibility of losing ill or injured detainees to follow-up within the
system after their arrival. Detainees who arrive by the usual means (such as a convoy or with a unit) are
usually brought immediately to the processing center and standard medical inprocessing can occur after
assignment of an ISN, if necessary. Detainees who arrive via ground or air ambulance or who are released
from the hospital should be medically inprocessed as well.
3-115. Complete medical records should accompany all detainees returning from another MTF. When a
detainee arrives at the processing center from another internment facility, health care personnel on-site
must review all medical documentation to identify detainees that require ongoing medication, physical
examination, or treatment. This information is given to the provider for disposition of the detainee. When
a detainee arrives from another MTF, records documenting prior treatment are essential for continuity of
care and are extremely helpful for the accepting medical staff in the ER.
3-116. Medical records and medications should accompany all returning detainees in order to assure
continuity of care. A summary and a complete record of studies for each detainee arriving from other
MTFs should be available electronically or in hard copy. Each interhospital transfer should always be
preceded by physician-to-physician contact in the form of a telephonic or an electronic communication. It
is also prudent to remember to extend the same courtesy when a detainee transfers from your care to
another TIF or MTF.
3-117. Required follow-up studies and treatment should be noted and easily accessible to assure
compliance with the treatment plan. Critical issues can be overlooked when a detainee transfers between
internment facilities. Therefore, it is practical to use redundant methods of communication (such as
transfer summary, telephone conversation, and e-mail summary). Because the detainee population can be
very large, it is critical to maintain a database of must-do items and each provider will have his own
tracking methods that work best. When detainees transfer specifically for studies or treatments, health care
providers must make every effort to provide timely feedback to the referring provider. Rules of medical
etiquette still apply in a CZ and no one wants to be left in the dark about a detainee’s outcome.
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AFTER HOURS MEDICAL AVAILABILITY
3-118. In addition to general transportation services, the organic or task-organized ambulance assets may
be used as a local emergency medical services (EMS) team. Guidelines for EMS functions and treatment
should be formulated with input from the physician staff, compiled and approved by the chief, emergency
medicine, and the hospital commander. In this role, the health care specialists on-shift answer calls
regarding acute detainee medical problems. These calls are generally routed from the compound to a
centralized control center, which logs the request and then contacts the EMS team by radio. The health
care specialists perform a brief problem-oriented history and evaluation and then call the ER physician to
report their findings and receive further treatment guidance. Depending upon the skill and scope of
practice of the health care specialists, this guidance may range from simple transport for further evaluation
to on-site treatment of the problem. This service should be available 24-hours per day and should cover
those times when the compound health care specialists are unavailable for immediate evaluation and
treatment.
HUNGER STRIKES
3-119. In the case of a hunger strike medical treatment or intervention may be directed without the
consent of the detainee to prevent death or serious harm. Such action must be based on a medical
determination that immediate treatment or intervention is necessary to prevent death or serious harm, and,
in addition, must be approved by the commanding officer of the detention facility or other designated
senior officer responsible for DO.
3-120. Procedures for identifying and referring to the medical staff, a detainee suspected or announced to
be on a hunger strike, will include obtaining an assessment from qualified health care personnel of whether
the detainee’s action is reasoned and deliberate or the manifestation of a mental illness. Upon medical
recommendation, the detainee may be placed in isolation.
3-121. Any detainee refusing food for 72 hours is considered to be on a hunger strike and will be referred
for medical evaluation and possible treatment. Health care personnel will isolate the detainee in a single-
occupancy observation room and denying contact with other detainees, when medically advisable. If
measuring food and liquid intake/output becomes necessary, health care personnel may place the detainee
in a special management unit or in a locked hospital room. The detainee may remain in the special
management unit, based on the detainee’s medical condition, until health care personnel determine a move
advisable. The medical officer will immediately report the hunger strike to the TIF commander.
3-122. Medical staff shall monitor the health of a detainee on a hunger strike. If the detainee is engaging
in a hunger strike due to a mental condition, appropriate medical action will be taken. During the initial
evaluation of a hunger-striking detainee, the medical staff will—
Measure and record the detainee’s height and weight.
Measure and record vital signs.
Perform a urinalysis.
Conduct a psychological/psychiatric evaluation.
Examine the detainee’s general physical condition and if clinically indicated, proceed with
radiographs and or laboratory studies.
Take and record weight and vital signs at least once every 24 hours during the hunger strike.
Take other medical measures as required.
3-123. If a large number of detainees participate in the hunger strike, then additional assets may be
required to prevent death or serious harm them.
3-124. After the hunger strike, the medical staff will provide follow-up medical and psychiatric care for
as long as necessary.
3-125. Before medical treatment is administered against the detainee’s will, the staff must make
reasonable efforts to convince the detainee to accept treatment voluntarily. Forced medical treatment will
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Medical Guidelines for Detainee Operations
be administered only after the medical staff determines that the detainee’s life or permanent health is at
risk.
SECTION IV — DETAINEE OUTPROCESSING
OUTPROCESSING PROCEDURES
3-126. Release is the process of returning a detainee to his country of birth or citizenship or to the point
of capture. A detainee who is not sick or wounded is released at the end of hostilities, or at any other time,
as directed by the OSD. Sick and wounded detainees will not be released against their will during
hostilities.
DETAINEE RELEASE PROCESS
3-127. For direct release of the detainee back into the community, the following requirements should be
met:
When required by the applicable Geneva Conventions, the detainee is advised in writing of the
release to enable him to notify his next-of-kin.
For release from a TIF, the following requirements should be considered: The SECDEF or his
designee will send official notification of transfer or release from the TIF and the applicable
staff agencies will execute orders that will delineate the responsibilities and procedures to
undertake.
The releasing unit must prepare, maintain, and report to the chain of custody and transfer/
release documentation according to current transfer and release procedures as directed by
the SECDEF.
Individual detainee preparation to include, at a minimum, segregation, outbriefing, medical
screening, and execution of conditional release statements for those detainees being
released.
Movement routes to transfer location. Coordinate all routes through the appropriate GCC.
Due to operations security (OPSEC) concerns, only make public notification of a release
and/or transfer in consultation and coordination with OSD.
3-128. For additional information on the detainee release process refer to FM 3-19.40.
SECTION V — MEDICAL LOGISTICS
FORMULARY
3-129. A formulary must be established for all MTFs providing detainee health support that is specifically
tailored to the detainee health care mission. The Defense Medical Standardization Board (DMSB) is a
joint DOD activity, which provides policy and standardization guidance relative to the development of
Deployable Medical Systems (DEPMEDS) and medical materiel used for the delivery of health care in the
Military Health System (MHS). In executing this mission, the DMSB maintains information to include
national stock numbers on all medications available within the MHS. This listing is available at the DMSB
Web site: http://www.jrcab.army.mil. The mailing address is Director, Defense Medical Standardization
Board,
1423 Sultan Drive, Fort Detrick, Maryland
21702-5013. The DOMD must ensure that
pharmaceutical requirements are identified and a formulary developed as early as possible in the mission
planning process. Specific planning considerations include—
Endemic and epidemic diseases in the AO.
Chronic health problems within the AO to include nutritional deficiencies.
Dosing requirements of various medications (such as requiring administration twice a day versus
four times a day).
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Detainee demographics (such as age and gender).
Medications currently available within the AO for civilian health care.
Special considerations (such as requirement to provide maternal/child, pediatric, and/or geriatric
health care).
Requirements for chemoprophylaxis (such as for malaria) and/or immunizations.
Sufficient stockage of medications to combat disease outbreaks within the detainee population
(such as meningitis, TB, or influenza).
3-130. In addition to medical supplies, the supporting MEDLOG unit will provide medical equipment
maintenance and repair and optical fabrication and repair services as required to the detainee population.
Coordination for this support is through the DOMD.
SUPPLY/RESUPPLY
3-131. In DO, a MEDLOG unit may not be available within the immediate AO. Coordination for Class
VIII (medical material) supply/resupply, medical equipment maintenance, eyewear fabrication, and blood
management takes on an added importance in DO. Prior to the operation, the number of days of supply,
which the in-country medical organizations will require is determined. A critical items list of supplies
which will be in high demand is also prepared. Preconfigured push packages must be developed to
maintain appropriate stockage levels in country until MEDLOG elements enter the theater, become
operational, and line order requisitioning procedures can be instituted.
3-132. In determining what supply items are to be stocked for DO, security and safety are prime
considerations.
MEDICAL EQUIPMENT
3-133. There are several factors to consider when equipping an MTF or hospital for DO—
Roles of treatment—In many hospital settings, it is possible to move patients to a higher role of
care to provide treatment not available at that particular location. However, in DO moving a
detainee to another facility may present a security risk or produce a logistical challenge. Ensure
you have the requisite diagnostic equipment for chronic and recurring medical conditions
present in the detainee population.
Availability of replacement parts/servicing—Ensure that the equipment available to the hospital
can easily be repaired or serviced by medical maintenance technicians. The availability of parts
or technicians that can repair or operate a particular piece of equipment may also add to
nonmission capable time. This may adversely affect the MTF’s ability to treat detainees on-site.
Lifetime of equipment—The equipment used in DO will receive a lot of use. The equipment
must be able to handle adverse environmental conditions and frequent or over use. Health care
personnel should perform operator maintenance frequently and be aware of potential equipment
failures due to extended use.
Compatibility with restraints—The equipment, especially beds and dental chairs, should always
be compatible with restraints.
3-134. Medical equipment used for DO will conform to Food and Drug Administration (FDA) standards
and maintenance intervals as required for DOD personnel and multinational forces.
SECTION VI — DETAINEE DECEDENT AFFAIRS
SECRETARY OF DEFENSE POLICY
3-135. Department of Defense Directive 2310.01E and AR 190-8 establishes the policy and procedures
for investigations of possible violations of protection afforded EPWs, RPs, civilian internees, and other
detainees (ODs), including procedures in cases of deaths of such persons. The body will be handled as
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Medical Guidelines for Detainee Operations
directed by the Office of the Armed Forces Medical Examiner (AFME). The determination of the cause
and manner of death will be the sole responsibility of the AFME or other physician designated by the
AFME.
3-136. Title 10 United States Code (USC) 1471, DODD 5154.24, and DOD Instruction (DODI) 5154.30
provide that the Office of the AFME has primary jurisdiction and authority within DOD to determine the
cause and manner of death in any DOD death investigations of EPW, RPs, civilian internees, and ODs in
the custody of the US Armed Forces.
DETAINEE DEATH NOTIFICATION PROCESS
3-137. When an EPW, RP, or detainee in US custody dies, the attending medical officer will immediately
notify the medical commander/DOMD, or the commander of the facility (or if the death did not occur in a
facility, the commander of the unit that exercised custody over the individual). The commander of the
facility will immediately report the death to the CID, the responsible investigative agency. The CID will
contact the Office of the AFME to determine whether an autopsy will need to be performed.
3-138. The attending medical officer will immediately furnish the TIF commander, medical
commander/DOMD, or other officer charged with the detainee custody before death, the following
information:
Full name of deceased.
Internment serial number of deceased.
Date, place, and cause of death.
Statement that death was or was not the result of the deceased’s own misconduct.
When the cause of death is undetermined, the attending medical officer will make a statement to
that effect. When the cause of death is finally determined, a supplemental report will be made.
3-139. The TIF commander, medical commander/DOMD or other officer charged with custody of the
person before death, will notify the DRS of the death immediately by the most expeditious means
available.
DETAINEE DECLARATION OF DEATH
3-140. Upon declaration of death, the remains will be placed in a clean body bag and secured awaiting
instructions from CID or from the appropriate investigating agency (if CID is not present in the AO, the
Navy Criminal Investigative Service or the Air Force Office of Special Investigations are the other
investigating agencies that can be used). The remains will not be washed and all items on or in the body
will be left undisturbed except for weapons, ammunition, and other items that pose a threat to others. The
body will not be released from US custody without written authorization from the investigative agency
concerned or the AFME.
3-141. The attending medical officer and the appropriate commander will complete a DA Form 2669-R
(Certificate of Death). The DA Form 2669-R will be reproduced locally on 8 1/2- by 11-inch paper. The
form can be found in AR 190-8 and will be used by the US Army only. Copies will be made out to
provide distribution as follows:
Original—Information center.
Copy—DRS, if necessary.
Copy—The Surgeon General as required by AR 190-8.
Copy—EPW, RP, or detainee personnel file.
3-142. The TIF commander will appoint an officer to investigate and report—
Each death or serious injury caused by guards or suspected to have been caused by guards or
sentries, another detainee, or any other person.
Each suicide or death resulting from unnatural or unknown causes.
3-143. One copy of the investigating officer’s report will be forwarded to the DRS.
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Chapter 3
3-144. Special agents from the CID will investigate deaths from other than natural causes per AR 195-2.
A copy of the CID report of investigation, if any, will be attached to the TIF commander’s report.
BURIAL, RECORD OF INTERMENT, AND CREMATION
3-145. If a detainee’s remains cannot be returned to his family, the deceased detainees will be buried
honorably in a cemetery established for them according to DA Pam 638-2 and FM 4-20.64. Deceased
detainees will be buried, if possible, according to the detainees’ religious beliefs, social and cultural
backg2round, and tribal or ethnic taboos. Deceased enemy prisoners of war, who cannot be returned to their
family or their government, will be buried according to the rites of their religion and customs of their
military force. Unless unavoidable circumstances require the use of collective (group or mass) graves,
detainees will be buried individually. The supporting mortuary affairs (MA) element will record any later
movement of the remains. The US will also care for the ashes of cremated persons. Ashes will be kept by
MA personnel until proper disposal can be decided according to the wishes of the power on which that
person depended. A body may be cremated only due to imperative hygiene reasons, the detainee’s
religion, or the detainee’s request for cremation. When a body is cremated, this fact together with the
reasons will be set forth in the death certificate.
3-146. If a detainee dies at sea, the body will not be buried there unless absolutely necessary. If the body
has to be buried at sea, the procedures prescribed for US troops will be followed as far as possible;
however, a US flag will not be used. When death occurs during a land transfer, the responsible officer will
follow the same procedures for burial prescribed for US military personnel.
3-147. The personnel file of a deceased person with all pertinent records will be forwarded to the DRS.
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Chapter 4
Functional Specialties
This chapter discusses different health care areas and/or services pertinent to detainee
health care operations.
SECTION I — NURSING SUPPORT TO DETAINEE OPERATIONS
4-1. Quality patient care must be provided regardless of the reason for the capture. This further
emphasizes the separation of custody and health care. Nursing care must be provided to the same
standards and quality that is given to nondetainee patients. Even in this highly stressful environment,
nurses must maintain compassion, concern, and professionalism, all of which are components of quality
nursing care.
FACILITY INPROCESSING
4-2. The established inprocessing area is where new detainees are brought for their initial inprocessing
into the TIF. Most of the inprocessing requirements are custody operations and are discussed primarily in
FM 3-19.40. The medical portion of inprocessing is covered with a medical screening process, which
normally includes: routine vital signs, height, weight, optometry screen, dental screen, immunizations,
review of systems, past medical and surgical histories, and a BH screen. All medical screening information
should be placed in the detainee’s individual medical record created during the screening process.
4-3. At a minimum, the nursing staff required should be the minimum number of MOS 68WM6s to
adequately complete all required tasks. The actual number should be based on workload (the average
number of detainees inprocessed).
4-4. Responsibilities of the nursing staff in the inprocessing area include all those tasks associated with
the medical screening process in a clinic. In addition to completing the tasks, documentation of all
immunizations and screenings must be completed. The detainee’s name and ISN are recorded on all
documentation.
4-5. The identification and documentation of abuse that has occurred at any point from time of capture to
time of screening is also an important function in the inprocessing area. Any time abuse is alleged,
suspected, or identified, it must be reported to the chain of command, DOMD, and the supporting CID.
CARE IN THE DETENTION COMPOUND
4-6. The majority of the care within the TIF can be provided by the health care specialists under the
supervision of a provider (such as a physician or a PA). The ratio of health care specialists to detainees
should be determined based on the overall health of the detainee population.
4-7. Advanced practice registered nurses (APRNs) may be used as physician extenders in the TIF for
those patients who require more in-depth care than the health care specialist can provide. The scope of
practice for APRNs is discussed in AR 40-68.
4-8. Disease management will be practiced in the TIF, with care focused on certain disease processes and
managed by a provider. Specialty clinics may be staffed for specific diseases such as diabetes to ensure
compliance with treatment regimens, to monitor disease progress, and to ultimately decrease unnecessary
use of emergency care.
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Chapter 4
INPATIENT/FACILITY NURSING CARE
UNDERSTANDING CULTURAL DIFFERENCES
4-9. Prior to deployment, the staff should receive instruction on cultural differences, especially those
relating to health care practices and beliefs, nursing practices in the locale, and roles. Other cultural
information such as general history of the country and political events leading up to the deployment should
also be addressed in order for the staff to understand why patients may act or respond in certain ways and
to understand the motivations of the people in general. Because of the great potential for treating HN
civilians in addition to the detainees, knowledge of the available health care in the immediate geographical
area is also helpful and will enable the staff to plan for adequate continuation of care after discharge from
the facility.
WARD
4-10. The nursing staff establishes and maintains the ward routine to include staff schedules and patient
activities. Ward rules are communicated to the detainee and are maintained by the staff. The nursing staff
ensures that all patient care activities are accomplished in a timely and safe manner. Nursing staff must be
conscious of security precautions at all times and ensure that all medical items and other items which could
be used as a weapon are properly secured.
SEPARATION OF CUSTODY AND HEALTH CARE
4-11. There must be a complete separation of custody and health care operations. No staff member will
participate in any form of custody operations at any time. Health care personnel do not provide guards for
detainees.
4-12. Interrogations will not be conducted on the ward. Health care personnel providing detainee medical
care will not assist or provide medical information to interrogators. Approval for interrogations to be
conducted with a detainee must come from the CDO and be routed through the DOMD and hospital
commander. Personnel from CID may conduct investigations with detainee, but only after notification of
hospital command/operations staff.
Supplies and Equipment
4-13. All supplies and equipment must be safeguarded to ensure they do not present a safety hazard to
detainees and staff. Ward personnel must be aware that even ordinary items, such as pens, pencils, or
plastic containers can be used to fashion a weapon. All supplies and equipment not in use should be
secured.
4-14. Vulnerability checks assess environmental safety and security in relation to DO in the inpatient and
outpatient care areas of the hospital. Vulnerability checks should be done at least weekly in each detainee
care area. Examples of vulnerability checks include checking for sharps at the bedside or the presence of
weapons in the detainee care area.
Alarms
4-15. A personal alarm system should be established to quickly gain staff reinforcement and back-up
security forces
(MPs) as necessary. Simple personal alarms such as a whistle are effective and
inexpensive. Alarms are sounded for detainee escape attempts, detainee attempts to overcome a staff
member, an uncooperative or combative detainee, minor or major disturbances, and any other instances as
deemed appropriate by the staff on duty.
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Functional Specialties
SECTION II — NUTRITION CARE
4-16. The mission of nutrition care is to provide comprehensive nutrition care, to include medical nutrition
therapy, nutritional assessment, nutrition risk screening of inpatients, nutrition education and health
promotion, consultation to the commander on nutrition-related issues pertaining to Soldiers, contractors,
and detainees. It is also to provide safe, wholesome foods to inpatients, including therapeutically modified
diets and consultation to the unit managing the contract for the detainees’ menu and feeding program.
NUTRITIONAL REQUIREMENTS
4-17. Army Regulation 190-8 provides guidance on the nutritional care of detainees. These requirements
are—
The daily food rations will be sufficient in quantity, quality, and variety to keep detainees in
good health and prevent loss of weight or development of nutritional deficiencies.
Account will be taken of the habitual diet of the prisoners.
Detainees who work may be given additional rations when required.
Sufficient drinking water will be supplied to detainees.
Detainees will, as far as possible, be associated with the preparation of their meals and may be
employed for that purpose in the kitchen. Furthermore, they will be given the means of
preparing additional food in their possession. Food service handlers must have training in
sanitary methods of food service.
ENTRANCE NUTRITION SCREENING
4-18. All detainees should be screened on entrance to the TIF as part of the medical inprocessing. As a
minimum, height and weight should be obtained and the BMI should be calculated to assess the detainees’
weight status and to identify detainees that are underweight. This can be obtained by nutrition care
personnel or by health care specialists trained to calculate and assess BMI. Detainees that are identified
with nutrition-related medical problems should be referred by the health care specialist, PA, or physician to
nutrition care. The BMI is calculated as weight in kilograms (kg) divided by the square of height in
meters, or using English units: multiply weight in pounds by 703 and divide twice by height in inches.
Assess BMI as follows:
Underweight: less than 18.5.
Desirable: 18.6-24.9.
Overweight: 25.0-29.9.
Obese: 30.0-39.9.
Morbidly Obese: 40 or greater.
Note. When the BMI is calculated by health care specialists or other nonnutrition care
personnel, underweight detainees are referred to nutrition care for consultation and further
follow-up.
MONTHLY DETAINEE WEIGHT TRACKING
4-19. Nutrition care personnel should be prepared to initiate or participate in monthly weigh-ins of the
detainees. The weights are recorded on DA Form 2664-R and this form is placed in the detainees’ medical
record. The weigh-ins should be coordinated with the TIF’s staff. The weigh-ins may be conducted during
detainee headcounts or during other times when the detainees are assembled as a group.
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CULTURAL CONSIDERATIONS
4-20. Upon notice of deployment, nutrition care personnel should familiarize themselves with the eating
habits and practices associated with foods in the area to which they will be deployed. These considerations
will need to be taken into account for menu design or recommendations and may even play a role in
feeding times during certain religious holidays. For example, the Iraqi diet is a high carbohydrate diet that
consists primarily of rice and Arabic flat bread, a variety of fruits and juices, vegetables
(such as
cucumbers and tomatoes), different vegetable/beef/lamb/chicken stews, eggs, and hot, sweetened tea called
chai. The Islamic diet consists of acceptable and forbidden foods. Halaal foods are considered lawful and
permissible, while Haraam defines unlawful and forbidden foods. Permissible foods include: all types of
fish, poultry, goats, sheep, cattle, camel, buck, buffalo, and rabbits. Haraam foods are pork and pork
products, all carnivorous (meat eating) animals and birds (such as lions, tigers, vultures, and eagles), any
Halaal animal that has died due to natural causes or been killed by a wild animal; food containing Haraam
items such as fish prepared with wine or desserts containing wine or other liquor. Contamination of a
Halaal item with a non-Halaal one will render it non-Halaal/Haraam and unacceptable. The utensils
should be separate when preparing Halaal and non-Halaal foods to prevent contamination. During the
Muslim holy month of Ramadan, the predawn meal is termed sahur, the breakfast meal, iftar is served after
sunset, and an overnight meal may be provided to maintain adequate caloric intake.
DETAINEE MENU
4-21. The dietitian has a responsibility in ensuring the nutritional adequacy of the menu served to the
detainees. A nutrient analysis should be performed using either an online nutrient database, such as the US
Department of Agriculture
(USDA), Agricultural Research Service National Nutrient Database
for Standard Reference, Release
20, available at the Nutrient Data Laboratory Home Page,
Based on this analysis recommendations are then made to the personnel in charge of negotiating the
contract feeding service. The primary nutrients of concern are: total energy, total protein, vitamins A, C,
D, Thiamin (B1), Riboflavin (B2), Niacin (B3), calcium, iodine, and iron. The menu should take into
account foods natural to the region and be in keeping with the detainees’ customary diet. Minimum
requirements can be based on the Dietary Reference Intakes (DRIs) values. Ideal estimates of protein
should be based on an individual’s weight, but can also be calculated as twelve to fifteen percent of total
calories. Many detainees will likely have wounds still in the healing process and thus require additional
protein to form new tissue. Vitamin C is needed on a daily basis as it is a water-soluble vitamin and its
primary sources are citrus fruits and fortified juices. Calcium is needed, in conjunction with vitamin D, to
maintain bone health and assist with healing fractures. Iron is needed to prevent anemia. Iodine
needs can be met by preparing foods with iodized salt. Recommended nutrient minimums, based
on the DRI, Food and Nutrition Board, Institute of Medicine (IOM) of the National Academies (available
Energy: 2500 calories.
Protein:
75-95 grams (g).
Vitamin A: 900 microgram (mcg) retinol equivalents.
Vitamin C: 90 mg.
Thiamin (B1): 1.2 mg.
Riboflavin (B2): 1.3 mg.
Niacin (B3): 16 mg.
Calcium: 1000 mg.
Vitamin D: 5 mg.
Iodine: 150 mcg.
Iron:
8 mg.
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DETAINEE FEEDING OPERATIONS
4-22. A smaller contingent of nutrition care personnel may deploy in the event that staff and detainee
feeding services are supplied by a contracted dining facility. The detainee menu may be managed by the
Logistics Staff Officer, US Army (S4) of the unit in charge of securing the detainees or another entity
involved in DO. A memorandum should be prepared daily to inform the contract dining facility personnel
of the food needs of the hospital. This memorandum should address detainee census, accounting for
potential admissions throughout the day, as well as extra food items to be distributed as nourishments to
the wards. Nourishments may include extra fruit, juice, milk, and nutritional supplements. The
nourishments should be adequate to provide snacks for in-between meals and at nighttime. This daily food
request will help prevent meal shortages, as well as food waste.
4-23. Use the space allotted to the nutrition care section to prepare therapeutic diets, to assemble detainee
trays, and to store and maintain supplies, nourishments, supplements, and enteral formulas. Within space
constraints, if feasible, set up pantry areas on the wards to expedite detainee feeding. However, nutrition
care personnel must always be aware of security concerns and not leave pantry areas unsecured. As a
minimum, the following equipment is required: refrigerator, microwave, blender for each section or pantry
area, table work surface, and shelves. Ensure or implement a system for ordering and retrieving food from
the contract dining facility or having the food delivered by the contract service to the hospital.
Additionally, as a minimum, set up a Class I (rations) account to have ready access to the medical diet
supplemental rations. Procedures for food service to detainees are governed by command policy and SOP.
Coordination between nutrition care and nursing staff is required. For additional information on medical
field feeding operations, refer to FM 4-02.56.
THERAPEUTIC DIETS
4-24. Therapeutic diets will be prepared to accommodate each detainee’s diet order per individual medical
record or DA Form 1829 (Hospital Food Service-Ward Diet Roster). The Manual of Clinical Dietetics,
published by the American Dietetic Association, is the primary reference for therapeutic diet instructions.
The menu components for these diets come from foods prepared by contract dining facilities, nutrition
supplements ordered through the hospital S4, and the medical diet supplemental rations. The following are
the primary therapeutic diets available under field conditions:
Detainees on a regular diet will use the standard menu provided for the detainee by the contract
dining facility. Detainee preferences, to include in-between meals and snacks, may be
incorporated into the diet to the maximal extent possible within the menu and available
supplement constraints.
Commercially prepared supplements
(such as high protein
preparations) provide a protein supplement and approximately 30 g of carbohydrate.
A high calorie/high protein diet is designed to provide additional calories and protein to the
regular diet. Additional calories and protein may come from the addition of snacks between
meals, increased portion sizes, nutrition supplements available, and milkshakes made with
nutrition supplements.
The clear liquid diet is designed to provide fluid and energy in a form that requires minimal
digestion. Between-meal snacks are encouraged to provide adequate calories. Diet consists of
broth, juice, gelatin, and sports drinks. This may be supplemented with a commercially
prepared protein-fortified clear liquid.
A blenderized liquid diet is designed to provide adequate nutrition to detainees unable to chew,
swallow, or digest solid foods. It may also be used as a transitional diet from clear liquid diet to
solid foods. The diet consists of foods and fluids blenderized to a liquid form that can be taken
through a straw. Between-meal snacks are encouraged to provide adequate calories and
nutritional supplements may also be included.
The mechanically altered diet is designed to minimize the amount of chewing required to ingest
foods and includes blended, chopped, ground, or pureed foods to promote ease of chewing.
Between-meal snacks are encouraged to provide adequate calories.
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A cardiac prudent diet is intended to assist with the reduction in serum cholesterol and consists
of modifications in fat, cholesterol, sodium, caffeine, and fiber. The dietitian or the nutrition
care specialist (MOS 68M) needs to work with the contract facility to ensure that the base
hospital diet is low in sodium and low in fat to accommodate the parameters of the diet.
Additional fruits and vegetables can be added to increase fiber.
A diabetic diet is intended to assist with maintaining or improving the blood glucose control of
diabetic detainees. At a minimum, the diabetic diet will provide three meals and one evening
snack per day. Carbohydrate consistency will be evenly distributed across the three main meals.
The amount of carbohydrates per meal will depend on the calorie level of the diet order.
CLINICAL DIETETICS
4-25. The detainees’ medical nutrition therapy will be planned and will include collaborative nutritional
screening, assessment, and monitoring to enhance recovery, promote optimal nutritional status, and
decrease health risks. Dietitians and nutrition care specialists perform the professional and supportive
duties required to ensure the prescribed diet is served.
4-26. Nutrition risk screening is accomplished for all detainees admitted to the hospital. The criteria for
nutrition risk screening will be locally developed and periodically updated. Detainees determined to be
adequately nourished will be rescreened at designated intervals prescribed by command policy and CSOP.
Typically, most intensive care unit (ICU) detainees should be seen by the dietitian. Nutritional care will be
documented in the detainee’s medical record and may include: subjective dietary history information;
objective medical, clinical, anthropometric, and diet order information; the assessment of the detainee’s
nutritional status; recommendations and or plans for implementation of nutritional intervention; and
quantifiable dietary goals. Inpatient nutritional care will be documented on the SF 509 (Medical Record—
Progress Notes) and outpatient care will be documented on the SF 600. The SF 513 (Medical Record—
Consultation Sheet) is used to document response to consultations. A dietetic consultation is not required
for a nutritional assessment.
SECTION III — EYE CARE
4-27. This section discusses the eye care provided to a detainee population. The eye care assets may be
task-organized from supporting medical treatment and MEDLOG units based on METT-TC and the
detainee workload.
4-28. The role of the eye care provider in DO will normally fall to an optometrist. Optometrists will
manage the day-to-day clinical aspects and refer detainees to the supporting ophthalmologist for specialty
care.
Optometrist. Independent primary health care provider who conducts examinations to detect,
prevent, diagnose, treat, and manage ocular related disorders. Additionally, conducts the initial
diagnosis and management of eye injuries.
Ophthalmologist. A medical doctor who specializes in eye and vision care. He is specially trained
to provide the entire spectrum of eye care and performs complex and delicate eye surgeries.
DETAINEE SCREENING
4-29. All detainees will undergo a vision screening, to include measurement of best-corrected visual
acuity, during inprocessing. The screening can be accomplished with a written form or done by interview.
If any problems are detected during the screening or if the best-corrected visual acuity is worse than 20/40
with both eyes together, then an SF 513 should be generated. At a minimum, the following information
should be obtained:
Is the detainee presently experiencing any problems with his eyes/vision?
Does the detainee wear/need glasses and if so, for what purpose? Are the glasses present?
Does the detainee have any history of ocular disease, trauma, or surgery?
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Does the detainee require medications for eye-related problems? What are the names of the
medications and are they present?
AUTOREFRACTOR PROTOCOL
4-30. In a detainee population, language barriers may present unique challenges to provider-detainee
interactions. The use of an autorefractor is a quick and accurate way to obtain objective information to
fabricate eyewear. A protocol to facilitate the use of the autorefractor is—
Detainees will receive a visual screening during inprocessing or as required during sick call.
Criteria for production of eyewear includes, but is not limited to—
Lost or broken glasses.
Complaint of decrease in vision.
Worse than 20/40 vision.
Health care specialists will check detainee visual acuity on eye charts in the detainee’s native
language when available. Detainees with vision of 20/40 or worse may request eyewear.
Screening of detainees with complaints of near-vision problems or over the age of 40 will be
done as prescribed in the CSOP.
Health care specialists operating the autorefractor follow the procedures provided in the
manufacturer’s instructions.
If the autorefractor reliability number is not six or greater, the test will be repeated up to three
times to get a better reading. If the reading remains low after repeated testing, these findings
will be reported to the optometrist.
Upon completion of the examination, the information is documented as prescribed in the CSOP
and transmitted to the theater fabrication facility for the production of the required eyewear.
Eyewear will then be distributed through the facility supply channels.
EYE EXAMINATIONS AND EYEWEAR
4-31. Detainees may get routine eye examinations for eyewear. This is done in coordination with the
physician through sick call and generation of an SF 513. The physician should attempt to obtain and
document on the consult, the chief complaint, duration of symptoms, and any eyewear present and best-
corrected visual acuity (if known). Detainees will be sorted by the indicated immediacy and date. The eye
care section will schedule detainees in the clinic. Detainees with uncorrected visual acuity of worse than
20/40 (with both eyes together) at distance or near are eligible for clear prescription eyewear. Eyewear
will be ordered as prescribed in the CSOP from the supporting MEDLOG unit. Eyewear is returned to the
physician or eye care section for dispensing.
EMERGENCY SERVICES
4-32. Any acute injury or presentation should be immediately sent to the eye care section for evaluation. If
the injury is beyond the capabilities of the eye care section then the detainee may need to be evacuated to
the supporting ophthalmologist. Detainee medical evacuations are arranged as required by the facility
SOP.
CATARACT SURGERY
4-33. The capability for cataract removal may not exist in a theater. Should these assets become available,
theater policy will be established to define eligibility criteria.
EYE TRAUMA AND SPECIFIC EYE DISEASE
4-34. For nonopen-globe trauma, the optometrist and/or physician should initially treat the trauma.
Determination can then be made of the need for evacuation for specialty care. Open-globe trauma merits
immediate transfer to an ophthalmic surgeon. The optometrist and/or physician at the TIF will manage
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glaucoma. In theater, it is unlikely there will be the required medical equipment to perform grid or pan
retinal photocoagulation for diabetic retinopathy. Detainees normally will not be evacuated out of the
country of capture for treatment.
DIABETES CLINIC
4-35. All newly diagnosed and processed diabetics should be sent to a multidisciplinary diabetic clinic, if
available. When medical assets are available, this clinic normally consists of optometry/ophthalmology,
podiatry, family practice, internal medicine, and nutrition care. The following documentation should
accompany the detainee when he attends the clinic:
Five days worth of twice daily random blood sugar readings.
A glycosylated hemoglobin (HgbA1c) test, blood chemistry, and urinary analysis (UA). The
last three tests should be within one week prior to the clinic.
4-36. At the clinic, the eye care physician/optometrist will conduct the following tests:
Refraction and best-corrected visual acuity.
Slit lamp exam of anterior chamber.
Dilated fundus examination of posterior chamber.
4-37. Retinopathy that needs treatment will be referred to the appropriate ophthalmologist, if such assets
are available in theater. Eyewear will not be ordered for anyone whose blood sugar is deemed
uncontrollable or significantly above the target value.
4-38. When medical assets are available within theater, podiatry will conduct a comprehensive foot
evaluation; family practice/internal medicine will conduct a physical review of systems and medications
and make recommendations about treatment; and nutrition care will educate about diet and portion control.
SECTION IV — EAR AND HEARING CARE
4-39. This section outlines the hearing assessment needs of the detainee population. It is important to
determine the hearing needs of each detainee. At a minimum, the following information should be
obtained:
Is the detainee presently experiencing any problems with his ears/hearing?
Is the detainee experiencing communication difficulties? Are such difficulties the result of
hearing loss? If so, does the detainee need medical treatment or an assistive listening device
(ALD)?
Does the detainee have any history of otologic disease, trauma, or surgery?
4-40. An audiologist or certified audiometric technician/ear-nose-throat specialist can provide the hearing
assessment. The level and type of care (such as an initial threshold screening versus diagnostic evaluation)
will depend on the staffing expertise available.
Audiologist. Independent primary health care provider qualified to provide a comprehensive
array of professional services to include audiologic identification, assessment, diagnosis, and
treatment of persons with impairment of auditory and vestibular function and prevention of
impairments associated with them.
Certified audiometric technician/ear-nose-throat specialist. Trained and certified to provide
initial hearing threshold assessments using the Defense Occupational Environmental Health
Readiness System—Hearing Conservation (DOEHRS-HC) or other microprocessor audiometer.
4-41. Detainees identified as having ear/hearing problems will undergo a hearing test, to include an
otoscopic inspection and air-conduction thresholds using the DOEHRS-HC test software. If any problems
are noted that require referral to an audiologist, then an SF 511 (Medical Record-Vital Signs Record)
should be generated.
Hearing testing must be performed in an acoustically-treated booth that meets or exceeds the
standards outlined in DA Pam 40-501, if available in theater.
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Diagnostic audiological equipment must be available on site or at an appropriate facility for
further detainee care evaluation when indicated.
4-42. Assistive listening devices should be available to detainees experiencing communication difficulties.
The ALD allows hearing impaired detainees the ability to communicate with other individuals and also
allows other individuals to communicate with a detainee who is hearing impaired.
SECTION V — BEHAVIORAL HEALTH SERVICES
4-43. Behavioral health services will be provided to detainees based on the availability of medical
resources and patient workload. Resources to provide this care may be task-organized and may include
inpatient and outpatient care. Health care personnel providing BH services to detainees may include a
psychiatrist, psychologist, social worker, BH nurse, occupational therapist, and BH specialist.
4-44. All detainees will receive a BH screen (Appendix B) at the time of inprocessing prior to distribution
into the general population. A translator will be used to translate between the screener and detainee. The
BH screen will be conducted by a BH team member. Each detainee will be screened individually to
maximize privacy. The BH screen will include whether the detainee has a present suicide ideation, history
of suicidal behavior, history of or current psychotropic medication use, current BH complaint, history of
BH treatment, and/or a history of treatment for substance abuse. During the BH screen, each detainee will
be observed for general appearance and behavior, evidence of abuse and/or trauma, and current symptoms
of psychosis, depression, anxiety, and/or aggression. After screening, each detainee will be recommended
for either placement into the general population, placement into the general population with appropriate
referral to BH, or referral to BH for an emergency assessment prior to movement into the general
population. The screening will begin with an introduction and explanation of the nature and purpose of the
screen. Each question will be asked by the screener and translated by the translator. Under no
circumstance will a translator conduct the screen. Behavioral health screening forms (Appendix B) will
not be presigned and detainees will not be screened in groups. The original completed screen will be
placed in the detainee’s individual medical record.
4-45. If the BH team member determines that a detainee is a suicide risk, based on the results of the
screening, he will ensure the detainee is placed on a suicide watch and will make a referral to a
credentialed BH provider as outlined on the screening form.
BEHAVIORAL HEALTH EVALUATIONS AND TREATMENT
4-46. All detainees who are referred for a BH evaluation will have an SF 513 completed by the consulting
physician/health care practitioner prior to the detainee being evaluated. The SF 513 will have, at a
minimum, the detainee identification information, a brief description of the symptoms, a clinical question
(such as “rule out depression”), and be signed by the referring health care practitioner. The comprehensive
BH assessment will include identification data, chief complaint, history of present illness, past BH history,
family BH history, past medical history, current medications, allergies, social history, BH review of
systems, mental status examination, formulation, multiaxis BH diagnosis, and treatment plan. Provider-to
provider communication from the consulting provider to the credentialed BH provider is required.
Feedback will be given to the consulting provider after the detainee has been evaluated and the treatment
team has formulated a treatment plan.
SUICIDE PREVENTION
4-47. To prevent detainees from attempting or committing suicide while in custody, all staff members must
remain alert for indications that detainees are possible suicide risks. This is done through comprehensive
intake screening, casual observations by health care personnel and/or TIF security personnel, reports from
other detainees concerning a detainee’s behavior, and other ways. Once a detainee has been identified as a
possible suicide risk, an assessment shall be conducted to try to determine the degree of such risk. Once
detainees have been identified and assessed as possible suicide risks, procedures and steps shall be taken to
protect detainees from self-harm.
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OBSERVATION AND DOCUMENTATION
4-48. Staff members shall continually observe detainees for indicators of possible suicide risk and will
accurately and thoroughly document all such observations. Detainees deemed suicide risks will be closely
observed and physically checked at specified intervals to ensure their safety. All staff members will follow
basic guidelines for the effective management and supervision of detainees deemed risks. This will feature
a high level of interpersonal interaction with detainees—listening to and talking with them. Detainees may
also use suicidal behavior to attain increased attention or privileges. Therefore, they may show absolutely
no signs of depression or distress.
Classification
4-49. Detainees will be properly classified for housing and level placement to facilitate the most effective
monitoring and supervision to ensure safety.
Referral of Detainees
4-50. Referrals of detainees who may be suicide risks shall be made to the supporting BH providers.
Behavioral health providers will follow through on all such referrals to determine most appropriate actions.
Security Procedures
4-51. Procedures shall be followed to minimize the possibility that detainees can harm themselves. This
will involve placement of detainees in suicide-resistant cells, removal of items that detainees may use to
harm themselves, and conducting thorough searches to uncover harmful items.
CRISIS INTERVENTION
4-52. Procedures will be followed to intervene in suicidal crisis situations of detainees, to de-escalate
difficult feelings and emotions, and to ensure safety. Steps, as prescribed in the TIF SOP, will be followed
to properly intervene in apparent hangings or other suicide attempts by detainees. This will include
appropriate follow-through procedures to calm detainees and ensure provision of appropriate medical and
psychological care. Following any detainee suicide attempt or completed suicide, appropriate written
reports are prepared fully describing elements of the incident. Traumatic event management (TEM) may
be conducted following serious suicide attempts or completed suicides of detainees. The purpose of such
debriefing is to analyze the incident and determine whether future suicide prevention procedures and
responses can be improved. In addition, TEM sessions may be scheduled for staff members involved in
serious detainee suicide attempts or completed suicides in order to address psychological/emotional needs
and concerns of staff members. A suicide prevention program is considered a team effort involving all TIF
staff.
OTHER RISK IDENTIFIERS AND ASSESSMENT OF DEGREE OF RISK
Indications of Severe Depression
4-53. Theater internment facility security personnel and other staff members must remain alert for
indications of possible suicide risk among detainees. Some of the more common signs and symptoms of
severe depression include—
Extreme feeling of sadness.
Apparent feelings of hopelessness and helplessness.
Guilt and self-blaming.
Lack of energy and lack of interest in activities.
Withdrawal from other people, including other detainees.
Eating problems (eating very little or too much).
Sleep problems (inability to sleep well or sleeping too much).
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Note. Any of the above indications of depression combined with a detainee’s talk of suicide,
wishing for death, or similar statements is a serious suicide indicator.
Other Indicators
4-54. Other indications of possible mental or emotional illness or distress include, but are not limited to,
the following:
Extreme agitation which lasts for longer than seems normal. This may be characterized by high-
level tension, anxiety, and possibly very strong emotions such as guilt, rage, or a wish for
revenge.
Alternating manic and depressed behavior. Manic behavior is commonly characterized by a
period of hyperactivity, racing thoughts, excessive talking, great energy, flight of ideas,
concocting grandiose schemes, claiming to need little sleep, and possible obnoxious behavior.
Unduly suspicious thought patterns.
Delusions and/or hallucinations.
Other Behaviors
4-55. Other behaviors which could indicate possible suicide risk, include a detainee—
Giving away possessions, particularly when he is not going anywhere.
Behaving (suddenly) in a very calm, resigned manner, particularly if he has previously been
agitated or depressed.
Harming or attempting to harm himself physically, even if it does not seem like an actual suicide
attempt. This is particularly significant if the detainee cuts himself in the neck area or makes
deep vertical cuts or slashes on a wrist.
Referral
4-56. If there is reason to consider a detainee a suicide risk for any of the above reasons, medical or facility
personnel will refer the detainee to BH for a professional suicide risk assessment. This is done by
completing an SF 513 or by simply communicating with a BH staff member.
DOCUMENTATION OF OBSERVATIONS AND INFORMATION
4-57. The person completing the intake screening form will accurately and thoroughly document any
information indicating that a detainee is a possible suicide risk. In addition, any staff member noticing any
indication that a detainee may be suicidal will document his observations in a log and contact the BH team.
4-58. Military police may make an initial classification decision of detainees as being on suicide-watch
status prior to a BH assessment.
4-59. If a staff member feels that a detainee should be carefully observed on a continuous basis in order to
ensure the detainee’s safety, he will place the detainee in an observation cell adjacent to the level control
point, if available. The detainee should be searched and all items that he can use in a suicide attempt
should be removed. Also, if the detainee makes suicidal gestures with articles of clothing he should have
everything removed from the cell except his underwear. The detainee should have continuous monitoring
while in the observation cell. The BH team should be notified and should evaluate the detainee prior to
returning him to general population. The TIF security personnel will log in each time a BH professional
evaluates a suicidal detainee.
4-60. Placing a detainee in the general population is a good option for a detainee who seems to be having a
difficult time, who may be having suicidal thoughts, and could well benefit from being around other people
rather than alone. However, this option should only be used if the other detainees with whom the suicidal
detainee is being housed can be trusted not to make him feel worse. If possible, the other detainees may be
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asked to keep an eye on the suicidal detainee; however, they should not be asked or directed to keep him
from committing suicide. In general, any detainee placed in general population will be considered a fairly
low suicide risk. The decision to return a detainee to the general population will be made by a BH
provider.
BEHAVIORAL HEALTH RECOMMENDATIONS
4-61. If the MP staff has any problems, concerns, or disagreements about any suggestions for care of a
detainee made by the BH staff, he will contact the chain of command. However, the MP shall not just
disregard the BH worker’s recommendation. In some cases, it may be helpful to ask a suicidal detainee to
agree to a nonsuicide pact. This is a short-term, time-specific agreement by the inmate not to attempt
suicide. It must be for a specific time frame, such as between the time of agreement and 0800 the next
morning. If it is not time specific, it is unreasonable and impractical. This tool can be especially useful
during nighttime hours, which are difficult for many people. It is a tool that can be used to help an inmate
get through a short but intense period of emotional crisis. If you use a pact, however, be sure to ask the
inmate to let you know if he feels, at any time during the period of time agreed on, that he cannot live up to
the agreement. A detainee’s nonsuicide pact must be reported to a BH provider.
MANAGING SUICIDAL DETAINEES
4-62. If a detainee seems to be undergoing a severe emotional crisis in which a suicide attempt seems
imminent, BH should be notified. Before professional help arrives, and if a detainee is actually about to
commit suicide, the staff member should do the following:
Approach the detainee calmly and with concern. Do not panic.
Ask how you can help.
Listen carefully without challenging. Avoid arguing with the detainee.
If necessary and if possible, physically prevent the detainee from harming himself.
REMOVAL OF DETAINEE FROM SUICIDE WATCH
4-63. If a staff member feels that a detainee may be safely removed from suicide-watch status, he may so
recommend to a supervisor. The supervisor will then assess the recommendation and the situation and, if
deemed appropriate, may then recommend to the BH team that the detainee be removed. The BH team
member provides the recommendation to the psychiatrist or psychologist for resolution. Under no
circumstances will TIF security personnel or other staff members remove a detainee from suicide watch
status without the permission of a BH provider. A credentialed BH provider will be consulted to determine
the appropriateness of removal from suicide-watch status.
INTERVENTION IN A SUICIDE ATTEMPT
4-64. If an MP or other staff member comes upon a detainee who is hanging, he will—
Immediately call for backup and notify the EMT personnel and the BH team.
When entering a tent or segregation cell, immediately lift the hanging victim’s body to relieve
pressure on his neck. Support the victim’s head when doing so.
Cut the item by which the detainee is hanging. Cut it either above or below the knot if possible,
so that the knot can be preserved as evidence.
Provide first aid, as required.
4-65. If a detainee has made a suicide attempt by any method other than hanging, the same basic sequence
for a hanging should be followed, except for cutting down the victim. The first aid applied will depend on
the specific method of suicide used by the inmate. If the detainee has made a cutting attempt, try to control
bleeding with direct pressure first. Call the EMT personnel to evaluate the detainee further. Whenever
possible, the detainee should be evaluated and treated in the compound. The responding EMT personnel
will determine if the detainee needs to be evacuated to an MTF for treatment. After medical treatment has
been rendered, the detainee should be observed in the observation cell until an evaluation by the BH
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professional can be accomplished. If the detainee took an overdose of medication, call the EMT personnel
immediately so proper care can be rendered. The BH assets should be notified after medical clearance has
been obtained. Following any suicide attempt by a detainee, the BH assets will be notified immediately
regardless of the time of day.
FOLLOW UP
4-66. The detainee should be placed in the observation cell after any suicide attempt that does not require
hospitalization. Additionally, staff members will log the incident into their respective logs and report to
higher HQ as directed by their internal SOP. In the event of a successful suicide, the staff member will
contact his immediate supervisor, higher HQ, and the BH assets immediately. Documentation into
respective logs should be completed.
4-67. The facility commander will review all incident report forms on suicide attempts or suicide incidents
to ensure compliance with policy and to be aware of any problems or concerns. In addition, the
commander has the option to schedule a session following any serious attempt by a detainee or a completed
suicide. The BH assets will talk with the involved staff members to review policy and discuss the event
after every serious attempt or completed suicide. Traumatic event management is highly encouraged but
not mandatory. Following a suicide, BH services will be made readily available for all staff members who
desire it.
SECTION VI — PREVENTIVE MEDICINE
4-68. Unit field sanitation teams as prescribed by AR 40-5 and FM 4-25.12 are the first line of defense for
ensuring that field sanitation standards and PMM are properly maintained. Preventive medicine personnel
will provide direct oversight and support to these teams, as necessary. Preventive medicine personnel may
be required to assist in establishing and/or inspecting a detainment facility. The United States Army Center
for Health Promotion and Preventive Medicine (USACHPPM) Technical Guide (TG) 307 provides
detailed public health standards, criteria, and guidance for planning, establishing, operating, and inspecting
internment facilities. Additional information on field sanitation devices
(for example latrines and
handwashing stations) is contained in Field Hygiene and Sanitation. Occupational and environmental
health surveillance are also required within the facility and if detainees are engaged in work at off-site
locations. This appendix provides a sample PVNTMED checklist for monthly inspections of DCPs,
DHAs, and TIFs (Table D-1).
POTABLE WATER
4-69. Preventive medicine personnel inspect water supplies for potability. Water point inspections are
documented on DA Form 5456 (Water Point Inspection). Preventive medicine personnel document the
inspection of potable water containers within the compound on DA Form 5457 (Potable Water Container
Inspection).
4-70. Water needs vary according to climate, sanitation facilities available, and the detainees’ normal
habits, religious, and cultural practices. Water consumption planning factors should be the same as for US
Forces. These factors are—
1.5 gallons per person per day for drinking in temperate climates.
3.0 gallons per person per day for drinking in tropical and arid climates.
2.0 gallons per person per day for drinking in arctic climates.
1.7 gallons per person per day for personal hygiene.
1.7 gallons per person per day for centralized hygiene (showers) (1 shower per week
per person).
2.8 gallons per person per day for food preparation.
3.1 gallons per person per day for laundry.
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1.24 gallons per person per day for medical treatment.
Detainees of certain religious faiths (such as Islam) should be provided an additional 0.5 to 1.5
gallons (2 to 5 liters) of potable water per person per day for washing and drinking associated
with religious practices.
Detainees who practice anal washing following defecation require an additional 0.25 to 0.5
gallons (1 to 2 liters) per day.
4-71. Sufficient potable water should be available to provide each detainee a minimum of 4 gallons (15
liters) per day. If detainees are preparing their own food, 8 gallons (30 liters) per day are required. Needs
may increase based on climate and religious/cultural practices. There should be at least one water
distribution point per 250 detainees.
4-72. Water quality must meet the field water requirements specified in Technical Bulletin, Medical (TB
MED) 577. Preventive medicine personnel inspect water supplies for potability, by testing them daily for
pH and free available chlorine (FAC) and conducting weekly bacteriological and chemical testing.
4-73. For showering and bathing, disinfected nonpotable water (with at least 1 parts per million [ppm]
FAC) may be used for centralized hygiene (such as showers) unless schistosomiasis and/or leptospirosis
are endemic and prevalent. Otherwise, potable water should be provided. Detainees should have access to
showers at least once per week. One showerhead should be provided per every 25 detainees.
4-74. Detainee clothing should be laundered at least once a week preferably in an Army field laundry or a
commercial central laundry facility. When centralized laundry services are unavailable, there should be at
least one clothes washing station per 100 detainees. Specific criteria for planning for detainee clothes
washing, to include water volumes and temperatures, are provided in the USACHPPM TG 307.
PEST MANAGEMENT SERVICES
4-75. Pest management activities are conducted within the TIF to reduce the incidence of disease within
the detainee population.
Vector/pest surveillance and control will be conducted as prescribed by TB MED 561. Fly
control shall be conducted according to Armed Forces Pest Management Board (AFPMB) TG
30. Mass delousing is rarely necessary and dangerous if done incorrectly. Infested detainees
should be kept separated from the general population until adequately treated on an individual
basis by health care providers, thoroughly showered with soap and water, and dressed
appropriately in laundered clothing.
Adequate collection and disposal of refuse is required to maintain adequate sanitation within the
facility. One 32-gallon refuse collection container is required per 25 detainees. If the detainees
prepare their own food, one 32-gallon container per 17 detainees is required. Inspections should
be conducted on a regular basis by the detainee supervisor or PVNTMED personnel to ensure
containers are covered to minimize attracting insects and rodents. These containers must be
emptied and cleaned daily.
Latrines and handwashing devices are established and maintained daily. The types and number
of latrines established are determined by the number of detainees and the length of time they
will be held at a location. For TIFs, latrines are normally provided at ratios of at least one for
every 25 male detainees and one for every 17 female detainees. Whenever possible, urinals
should be provided at a ratio of at least one for every 50 male detainees. Urinals may replace up
to 50 percent of the male latrine requirement. Field expedient measures (such as individual
waste collection bags) may be required at temporary locations, such as the DCP. Facilities must
be maintained properly to control fly populations. Handwashing devices should be located
between or adjacent to all latrines and urinals. There should be at least one handwashing device
per every five latrines.
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FOOD SANITATION
4-76. Preventive medicine personnel ensure that food service facilities that serve detainee populations
meet all food service sanitation requirements specified in TB MED 530. Only food from approved sources
may be used. The detainee food service operations must be inspected routinely for sanitation and the
results of these inspections are documented on DA Form 5162-R (Routine Food Establishment Inspection
Report).
4-77. If food is prepared at a central dining facility and brought to the detainment facility in insulated food
containers, particular attention must be paid to holding temperatures and maximum time food can be served
from the container. Keep cold foods below 40° Fahrenheit (F) (4° Celsius [C]) and hot foods above 140°F
(60°C) to prevent bacterial growth. Food should be served within 3 hours of preparation.
4-78. If food is prepared in the detainment facility, food preparation and handling areas should be screened
to exclude flies and other pests from exposed food. Food service personnel must meet the medical
screening and food service sanitation training requirements outlined in TB MED 530. Therefore, if
detainees normally prepare and handle the food, they must be trained in food preparation and handling by
qualified personnel.
4-79. Detainees may also have personal food items within their designated living space. These items
should be inspected to ensure food hygiene and safety requirements are adhered to. Containers used to
store these items must protect them from potential contamination such as from insects and dirt.
Additionally, if the food item is sensitive to heat and/or cold, it must be maintained in a manner that will
protect it from spoilage.
4-80. It is possible that a detainee may bring into the facility a domesticated animal and may then request
permission to slaughter the animal. If so, the supporting medical command (MEDCOM) and other medical
command and control (C2) unit should be contacted to coordinate veterinary service support.
4-81. Preventive medicine personnel provide sanitary control and surveillance of food preparation and
dining facility sanitation. Food service facilities for detainee populations must meet the sanitation
requirements provided in TB MED 530 and Field Hygiene and Sanitation. Detailed food service sanitation
guidance, including kitchen locations with respect to other facilities; use of locally procured foods; food
protection; food service worker training; handwashing facilities; soakage pits; mix of meals, ready-to-eat
(MREs) and hot meals; and cultural and religious considerations are described in the USACHPPM TG 307.
ENVIRONMENTAL SANITATION
4-82. Preventive medicine personnel also inspect detainment facilities for environmental sanitation. To
enhance sanitary conditions, they provide training in personal hygiene practices and field sanitation to
detainees. Standards for personal hygiene and field sanitation practices should be posted in detainee areas
in their native language and explained to them upon initial entry into the facility.
4-83. The safe disposal of wastes creates the first barrier to direct and indirect transmission of disease.
The provision of appropriate facilities for urination and defecation and for solid waste management is
essential for detainee health, safety, and dignity.
4-84. Human wastes should be disposed of in latrines that are designed, constructed, and maintained in a
sanitary manner and acceptable to detainees, taking into account cultural norms, ease of cleaning, and
privacy. At least one latrine should be provided per every 25 males and one latrine per every 17 females.
4-85. The USACHPPM TG 307 provides specific guidance on human waste disposal in austere
environments; the variety of latrines and urinals available for field use; locations of latrines with respect to
water supplies and food service areas; availability of toilet paper and handwashing devices; and the use of
privacy screens.
4-86. Refuse containers (33 gallon) should be provided at a ration of one for every 25 detainees and should
be clearly marked, lined with plastic bags, and covered with tight-fitting lids. Additional guidance for
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refuse container location; collection frequencies; burial, and incineration is provided in the USACHPPM
TG 307.
4-87. Ideally regulated medical wastes should be disposed of using modern, high-quality incinerators
available at local national hospitals or through contractors. If unavailable, medical wastes should be
separated and disposed of in a correctly designed, constructed, and operated inclined-plane incinerator with
a vapor burner, as described in FM 4-25.12. Additional guidance regarding medical waste disposal if
found in the USACHPPM TG 307.
CONTROL OF COMMUNICABLE DISEASES
4-88. Medical screening for communicable diseases must occur at inprocessing and during monthly
medical exams according to AR 190-8 and theater policy. Detainees are immunized based on theater
policy. Seriously ill detainees, especially those with communicable diseases, should be segregated from
the general detainee population. Detainees with respiratory infections, especially TB, should be masked
with a standard surgical mask and segregated in areas that do not share recirculated air with the remainder
of the population until they are no longer infectious.
4-89. Medical surveillance data must be collected, analyzed, and reported for the detainee populations at
detention facilities. Detainee DNBI data is collected daily and reported at least weekly through medical
channels according to theater policy.
GUIDELINE LISTING
SITE SELECTION AND SHELTER
4-90. Detention facilities can vary greatly, from short-term holding areas in forward locations that may
consist of little more than several strands of concertina wire, to large, long-term I/R facilities that house
thousands of detainees. Poor site selection and facility design can increase the risk of disease and injuries
for detainees and for cadre.
4-91. Refer to USACHPPM TG 307 for comprehensive guidance on site selection, shelter, water, food,
waste management, vector and pest control, and basic communicable disease control.
4-92. To determine total land area requirements, use a minimum factor of 320 square (sq) feet (ft) (35 sq
yards [yds], or 30 sq meters) per person to ensure ample space for shelters, roads, firebreaks, public
facilities, and administrative and support facilities, such as medical. For a 5,000-person internment facility,
the minimum land area is about 37 acres.
4-93. Covered living space should provide a minimum of 40 sq ft per person. Air circulation is improved
and respiratory disease rates lowered if more space can be provided (up to 80 sq ft). Beds or mats should
be separated by a minimum distance of 2.5 ft. Maximum occupancy for military tentage is 20 occupants
per general purpose (GP) large and 12 occupants per GP medium. Small shelters with few occupants are
preferable to large shelters with many occupants.
4-94. Adequate ventilation is critical. The minimum amount of air circulation needed is 12 cubic ft per
minute (cfm) per person, at least 4 cfm (33 percent) of which should be fresh (outside) air. Recirculated air
should be filtered. Natural ventilation may be adequate to achieve this degree of circulation in temporary
shelters such as tents, but mechanical ventilation will likely be required to comply with these standards
inside buildings. Ambient temperature in shelters should be maintained at 66°F to 78°F, but lower
temperatures may be acceptable if detainees are provided warm clothing and blankets. Relative humidity
should be maintained between 30 percent and 50 percent in buildings. A minimum of 20 foot-candles of
light should be provided at 30 inches from the ground for all interior spaces.
4-95. Site selection and facility design criteria considers land topography; drainage; space for people and
support facilities; vectorborne disease threats, like mosquito and rat breeding areas/food sources; roads,
firebreaks; shelter spacing; and facility layout. Detailed sanitation and hygiene criteria for site selection
and facility layout are found in the USACHPPM TG 307.
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CLOTHING
4-96. Each detainee is provided distinctive clothing (such as brightly colored jumpsuits) in sufficient
quantity. Detainees should be issued permethrin-impregnated clothing, which are normally effective for 20
washings before requiring retreatment. Only trained personnel using proper equipment and/or supplies
should apply permethrin. For additional information on clothing and the marking of clothing refer to FM
3-19.40.
PREVENTIVE MEDICINE INSPECTION PROCEDURES
4-97. A critical element in the prevention of disease and injury is consistent monitoring and evaluation.
Detention facilities require regular, periodic assessment of the sanitary and hygiene standards and
requirements and to ensure the overall appropriateness, effectiveness, and impact on detainee populations.
Preventive medicine personnel should be knowledgeable of detainee facility policies and procedures, as
well as the local cultures, customs, and endemic, environmental, and communicable disease threats.
SECTION VII — PHARMACY SERVICES
RESPONSIBILITIES
4-98. The MTF commander is responsible for operation of the pharmacy and exercises careful supervision
over all phases of its operations. At Role 1 and 2 MTFs, the senior physician supervises the receipt,
storage, and issuance of medications. The chief, pharmacy services at the supporting Role 3 hospital
provides consultation and assistance on pharmaceutical issues arising at the supported facilities. Within the
Role 3 hospital, the commander ensures that—
Supervision is exercised directly, either by a—
Subordinate officer who is a graduate of a recognized school or college of pharmacy and
licensed to practice pharmacy in one of the states of the US, Puerto Rico, or the District of
Columbia.
Physician acting as the officer in charge
(OIC) or in an equivalent status when no
pharmacist is on duty at the facility.
Policies are established to ensure—
Rational prescribing, taking into consideration pharmacoeconomic aspects of various
medication alternatives so that health care providers use cost-effective therapies at the MTF.
Quantities of drugs prescribed do not exceed amounts required to provide sound medical
treatment. Detainees are not permitted to retain medications in their possession with the
exception of such medications as fast-acting inhalants for asthma.
Prescribed medications are available in individual dose packaging.
When feasible, medications are prescribed that require administration only one or two times
a day.
4-99. The pharmacy chief is charged with the duties of recognizing, identifying, selecting, ordering,
preparing, safeguarding, evaluating, and dispensing all pharmaceutical substances of whatever kind and
combination used in preventive, curative, and diagnostic medicine. The chief and his staff are responsible
for keeping abreast of new developments in the field of pharmacy and for operating the pharmacy in
compliance with federal laws, accreditation standards defined by the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), when applicable, and standards of pharmaceutical care as prescribed
by AR and policy. In doing so, the chief is responsible for—
Assisting and advising health care providers in the writing of prescriptions, medication orders,
and other matters involving the use or misuse of medications.
Inspecting locations within the facility where medications are stocked/stored.
Ensuring documentation for the administration of medications to detainees is completed and
maintained. If appropriate, documentation on the administration of medications to detainees or
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a detainee’s refusal to take prescribed medications will also be filed in the individual detainee’s
medical record.
Maintaining adequate reference material for use by pharmacy personnel and other professional
staff served by the pharmacy.
Disseminating information to the professional staff concerning advances in the field of
pharmacy and related matters.
Disseminating via appropriate media
(for example, memorandums or e-mail), pharmacy
information on drug items, preparations available for use, prescribing policies, and items of
interest to the medical staff.
Operating a pharmacy sterile products program within the hospital to include the preparation
and delivery of pharmaceutical sterile products to patient care areas.
Operating a unit dose or other point of use drug distribution system to ensure a safe, efficient,
and economical method of drug distribution.
Consulting with the professional staff on the appropriate use of medications, including
interactions and cautions related to the use of alternative forms of medicines such as dietary
supplements and herbal remedies, if appropriate.
Conducting staff assistance visits and consultation services to Roles 1 and 2 MTFs organic/
collocated with the TIF.
CONTROLLED SUBSTANCES
4-100. Controlled substances are drugs so designated by the DEA. The DEA assigns controlled
substances to one of five schedules according to the abuse potential and degree of control required. A list
of controlled substances in each schedule and changes are published in the Federal Register and in the
Supply Bulletin (SB) 8-75-series.
4-101. Military treatment facility commanders may designate items as locally controlled if they deem
them subject to potential abuse or diversion. The method of accountability for such items will be either as
Schedule II or Schedules III-V as determined by the commander.
4-102. The receipt, storage, distribution, and inventory of controlled substances are prescribed in
applicable regulations, policies, and established procedures and standards.
INDIVIDUALS AUTHORIZED TO WRITE PRESCRIPTIONS
4-103. Uniformed physicians, dentists, veterinarians, and podiatrists engaged in professional practice at
MTFs are authorized to write prescriptions.
4-104. The following personnel are authorized to write prescriptions only for selected medications as
established under the provisions of AR 40-68 and/or approved by the local commander:
Uniformed optometrists, APRNs, PAs, physical therapists, occupational therapists, and
pharmacists engaged in professional practice at MTFs and privileged to prescribe medications.
Other nonphysician health care providers not listed above but assigned to an MTF and granted
limited prescribing privileges.
Contract civilian health care providers as permitted by their credentialing and scopes of practice.
SIGNATURES
4-105. With the exception of physician order entry via the Armed Forces Health Longitudinal
Technology Application (AHLTA), no prescription or order will be filled in the pharmacy unless it bears
the signature of an individual authorized to write prescriptions. Signature stamps are not authorized for
prescriptions. The pharmacy service will maintain a system that allows their staff to validate the signature
of individuals privileged to write prescriptions within their MTF.
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4-106. Ward stock orders for controlled substances will be signed by individuals authorized to write
prescriptions or by a registered nurse.
4-107. Medical treatment facilities with electronic ordering capability may use electronic signatures if
security measures are provided.
Dispensing
4-108. The MTF commander/physician ensures adherence to the DOD Tri-Service pharmacy policy
guidance for dispensing medications. Wards, clinics, and other activities within the hospital will normally
use the pharmacy as the source of supply for drugs required for administration within the MTF. Roles 1
and 2 MTFs will adhere to established procedures in the unit SOP.
4-109. Dispensing procedures.
All medication will be dispensed only upon receipt of a properly written or automated
prescription.
Military treatment facilities will follow a generic dispensing policy. Orders written by staff
providers for trade name drugs will automatically be dispensed with the generic equivalent when
possible.
The MTF will develop written procedures for dispensing controlled medications that comply
with federal laws and ARs.
Prescription Forms
4-110. Department of Defense Form 1289 (Prescription Form) is the standard form. Information
pertaining to drug manufacturer, lot number, and expiration date is not required on any DD Form 1289
written in an Army MTF, if there is a drug recall procedure established that can be readily implemented.
DD Form 1289 is not used for multiple medications, single prescriptions only.
4-111. The MTF commander/physician may authorize use of a locally developed multiple prescription
form. The MTF commander/physician may authorize use of other official forms for use in prescribing
medications (for example, SF 600, SF 558, or DA Form 4256 [Clinical Record—Doctor’s Orders]).
4-112. Bulk drug orders, DA Form 3875 (Bulk Drug Order), a local form, or an automated system will be
used for ordering all noncontrolled drugs or preparations in bulk quantities for use in a ward, clinic, or
other activities. Items requiring maintenance of a stock record card will be issued only upon receipt of a
properly written and authenticated prescription form or locally approved form.
Prescription Writing
4-113. Prescriptions will be stamped, typed, or written in ink and signed in ink by an authorized
prescriber. As an exception to this rule, electronic prescriptions generated through AHLTA, to include
prescriptions for Schedules II through V controlled substances, may be filled by the pharmacy contingent
upon established security measures (see AR 40-3). Otherwise, prescriptions for Schedule II substances
require an original prescription.
4-114. Prescriptions will be dated and signed on the day when written.
4-115. In accordance with current policies, authorized military and DOD providers who are authorized to
prescribe, dispense, and administer controlled substances will record their DEA number or social security
number on all prescriptions written for controlled substances in the course of their official duties.
4-116. Prescriptions for controlled substances written at Army MTFs will have the amount prescribed
shown both in numerals and spelled out in words.
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Accounting for Controlled Substances Used in the Manufacture of Pharmaceutical
Preparations
4-117. Department of Defense Form 1289 or an equivalent automated record will be used to account for
all controlled substances used in the manufacture of pharmaceutical preparations. Such orders will be
authenticated and signed by a licensed provider or registered nurse and will be filed in the appropriate
prescription file.
Labeling
4-118. Labeling requirements for drugs issued in bulk to wards, clinics, and other authorized agencies
will be prescribed by the commander. The container label will include the drug name and strength,
manufacturer, lot number or locally assigned lot number, and expiration date.
4-119. Labels for intravenous admixture solutions prepared by the pharmacy service will comply with
federal law and appropriate standards of practice.
Numbering and Filing
4-120. All hard copy prescriptions and orders filled by the pharmacy will be placed in files established
and maintained in the pharmacy. Controlled substance prescriptions will be numbered serially and signed
for by the individual who picked up the medication. Two series of numbers will be used; one series for
Schedule II controlled substances, alcohol, and alcoholic liquors and one series for Schedules III, IV, and
V controlled substances. A corresponding file will be established for each series of numbers. Pharmacies
using AHLTA or any other computer system will develop a suitable alternative method to number, check,
and file prescriptions.
Stock Record
4-121. The pharmacy/MTF will maintain a record of receipts and expenditures of all controlled
substances, ethyl alcohol and alcoholic liquors, and of such other drugs as may be designated by the
commander. A separate record will be maintained on DA Form 3862 (Controlled Substances Stock
Record) for each dosage form in which the item is supplied except where an equivalent locally approved
automated accounting record is used.
Disposition of Drugs Confiscated from Detainees
4-122. At the point of capture, medications found on detainees will be confiscated, inventoried, placed in
a bag, and identified with the detainees name and capture tag number. Health care personnel will
determine what condition the medication is being taken for and whether it was prescribed by a doctor.
(In
many cultures, medications that require a prescription in the US can be purchased over the counter.
Detainees may, therefore, be self-medicating and not under the care of a doctor.) If it is medically
determined that the detainee requires daily medication, appropriate arrangements will be made for the
administration of the required medications while in temporary holding facilities or while en route to the
TIF.
4-123. Medications will be provided to health care personnel during the TIF inprocessing medical
screening.
4-124. Health care personnel will determine the disposition of medications confiscated from detainees.
4-125. With the exception of the types of medication discussed in paragraph
4-126, medications
possessed by detainees while in the TIF are considered contraband and will be confiscated. Contraband
will be documented and then destroyed under medical supervision.
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Self-Administration
4-126. Detainees may be allowed to administer medications to themselves when a delay in receiving
medications may adversely affect the detainee’s health or when the detainee is receiving topical products
on an as-needed basis. Albuterol inhalers and topical creams and ointments are suitable examples. In all
cases, the detainee’s name and ISN (or capture tag number) will be placed on the medication package or
the medication itself.
INSPECTION AND DISPOSITION OF PRESCRIPTION FILES AND
RECORDS
4-127. Prescription and allied records will be subject to inspection at all times.
4-128. Prescription files, controlled substance records, and other records maintained in the
pharmacy/MTF will be retained and disposed of according to AR 25-400-2. Any alternative method of
storage and disposal must be approved by the appropriate records management officer.
SECTION VIII — DENTAL CARE
DENTAL RESOURCES WITHIN THE THEATER
4-129. This section discusses the policies and procedures for providing dental care to a detainee
population. Limited detainee emergency dental care can be provided by the physician and PA at a Role 1
MTF and consists of the relief of pain and antibiotics to treat infection. Operational dental care is provided
by the dental officer in a Role 2 MTF and a dental company, area support. Operational dental care consists
of emergency dental care and essential dental care. Essential dental care consists of definitive restoration,
minor oral surgery, endodontic, periodontic, and prosthodontic procedures, as well as prophylaxis.
4-130. At Role 3 hospitals, a maxillofacial surgical capability is available to minimize loss of life and
disability resulting from severe oral and maxillofacial injuries and wounds.
4-131. The size of the dental element providing support to a TIF is dependent on METT-TC factors
including the size of detainee population and availability of dental resources in the geographical area.
Dental personnel and equipment are not organic to MP unit/TIF medical sections and therefore
augmentation of dental assets is required.
CONCERNS AND ISSUES DEALING SPECIFICALLY WITH
DETAINEE DENTAL OPERATIONS
4-132. The primary unique concern in detainee medical operations is security. Designing the placement
and location of chairs and the clinic floor plan de-emphasizes detainee privacy and increases emphasis on
security within the TIF. Equipment and supplies should be accounted for at all times. All instruments
should be inaccessible to detainees. Detainees should be visible to guards at all times. Detainees should
not have ready access to exits. During detainee treatment times, staff weapons are not permitted in the
clinic.
EXAMINATIONS
4-133. Initial screening examination of detainees is used to identify obvious swelling, trauma, abscess,
excessive bleeding, and lesions.
Screening is done as a “look-see,” which is completed by using a flashlight and tongue
depressor.
When one or more of the above are noted, the detainee should be brought to the dental clinic
immediately for a more involved examination with x-rays and treatment, if necessary.
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Prescriptions are written as deemed necessary for the treatment of the detainee’s dental
condition.
4-134. Screening examination findings are recorded on SF 603 (Health Record—Dental) and placed in
the detainee’s medical record which was initiated during the medical screening conducted when the
detainee was inprocessed to the TIF.
Obvious findings recorded include extractions
(such as root tips or nonrestorable caries),
restorable caries, and partially impacted wisdom teeth.
Detainees are asked if pain is involved and the response is noted.
TREATMENT SCREENING PROCEDURES
4-135. After detainees have been medically inprocessed to the TIF, periodic screens may be required to
intercept dental emergencies.
4-136. A specific detainee may be referred for dental evaluation and treatment from a number of areas.
The procedure for requesting a specific detainee to report for dental evaluation and treatment is to provide
a memorandum to the MPs the night before, requesting the detainee report in the morning. Detainee can be
referred by—
Consults turned in from doctors.
Medical inprocessing screens.
Sick call.
Follow-ups from the previous day.
4-137.
When detainees come for treatment, treatment is documented on a new SF 603.
The detainee’s name and ISN is written in pen and his domicile location is entered in pencil as
this may change.
The SF 603 and any SF 603A (Medical Record—Dental-Continuation) are maintained in the
detainee’s individual medical record. The medical record is requested from the supporting
PAD, as required.
4-138.
Evaluation and determination of required treatment consists of the following—
The dentist and translator screen the detainee’s medical history for any adverse reaction to
previous dental treatment.
The detainee is asked where and what kind of pain he is experiencing. This is documented on
the SF 603A.
Radiographs are taken of the teeth that the detainee has complained about. The dental officer
determines whether other teeth need to be x-rayed that may require dental treatment.
Once taken, the dentist is notified and reads the x-ray. The assistant is then told what type of
treatment to set up for.
Detainees are informed through a translator of treatment required.
They have the opportunity to either accept or refuse treatment.
If treatment is refused, they are informed of the complications that may result from not
having treatment.
4-139.
Detainees often do not get to eat breakfast before they come in the morning; therefore, the dental
clinic maintains nutritional support drinks in the clinic, for those detainees who—
Need to take pain medication immediately.
Will have extensive oral surgery (several teeth taken out in one day).
Are diabetic (given before receiving treatment).
4-140. Once the dental procedure is completed, if a—
Prescription is required and subsequently written; it will include the detainee’s name, ISN, and
domicile location.
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Stat dose is written, the assistant will take it down to the pharmacy to have it filled.
Prescription is written for the detainee to take later; this is indicated across the top and turned in
to the pharmacy.
4-141. Once the detainee is finished with the dental procedure, the MP is asked to return the detainee
back to the compound, hospital ward, or holding cell, as appropriate.
Postoperative instructions are given through a translator.
An immediate dose of medicine is given (if required).
(Detainees are not permitted to have
medications on their person. After the initial medication is given in the clinic, other doses of the
medication will be provided per established procedures in the TIF SOP.)
The guard is asked to bring in the next detainee. For security reasons, a maximum number of
detainees permitted in the clinic at one time is established. This is dependent upon the size of
the area and the number of providers.
Follow-up detainees will be requested and seen as needed.
WEAPONS
4-142. No weapons are allowed in the clinic when detainees are scheduled. Weapons are turned in at
PAD office. If individual detainees are treated during nonscheduled hours, weapons are turned in at PAD
office or stored in secure areas within the clinic.
TRANSLATOR
4-143. A translator is required during all dental treatment of detainees. The translator is required to assist
the dental officer in ensuring the medical history is accurately reviewed, to inform the detainee of the
procedures to be performed, and to translate the concerns of the detainee to the dental officer and of the
dental officer to the detainee during treatment.
PHOTOGRAPHS AND RADIOGRAPHS
4-144. There are stringent regulations pertaining to the photographing of detainees. Medical photographs
will only be used to document preexisting conditions and traumatic injuries and to provide a basis for
justification of why treatment was performed. Any medical photographs taken become a part of the
detainee’s medical record.
SICK CALL AND EMERGENCIES
4-145. Dental emergencies (such as bleeding, externally expanding abscesses, pain, and trauma) are
treated immediately after ER notification, dental evaluation, and confirmation of urgency.
HOSPITAL PATIENTS
Inpatients
4-146. Inpatients are treated on a per-consult basis either at the bedside or in the clinic based on
ambulatory capacity. All detainee inpatients must be under guard when leaving the ward and continuously
while they are off the ward. Detainee inpatients cannot move within the facility or to the clinic unless
under guard.
Dental Inpatients
4-147. Detainees admitted for reasons related to dental emergencies may be admitted by the ER physician
per dental consult and emergency care required. Discharge is per mutual agreement between medical and
dental staff.
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SECTION IX — VETERINARY SERVICES
4-148. Veterinary service support requirements for DO are based on the mission and the size of the force
supported. Veterinary units inspect food production sites for safe food manufacture storage and
conveyance. These units are responsible for sanitary inspections and food screening at places of
procurement, production, storage, and conveyance. These inspections are an integral part of assuring food
safety, security, and quality assurance for detainees.
4-149. Veterinary units will provide animal medical care to military working dogs (MWDs) located at the
TIF. This support provides Level I and II veterinary care that includes emergency treatment, stabilization,
and evacuation. Refer to FM 4-02.18.
4-150. Veterinary personnel have oversight of the husbandry and welfare of any animals maintained for
food in the facility and will assist with oversight of animals slaughtered on premises to prevent conveyance
of illicit material in the animal carcass, as well as to confirm safe food handling practices.
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FMI 4-02.46
8 November 2007
Appendix A
Medical Code of Conduct in Detainee Operations
This appendix discusses the rules of conduct for all medical personnel involved in
providing health care to detainees. This appendix discusses the interactions of such
personnel with each other, with detainees, and with detainee family members. It
prescribes certain activities of personnel who, by reason of their duty assignment or
of their entrance into an MTF providing health care services to detainees, are subject
to the jurisdiction of the MTF commander and/or the commander of an internment or
holding facility.
SECTION I — DEFINITION OF TERMS
A-1. This section defines terms used in this appendix to ensure there is a clear understanding of the
parameters of the code of conduct. When the term will is used, compliance is mandatory. When the term
may is used, it is permissive.
A-2.
Terms requiring definition are—
Anything of value includes, but is not limited to: money, food, candy, photographs, any items
defined as contraband or any other gift or personal service having monetary
(however
negligible), informational, or even merely sentimental value.
Contraband is any item, article, or substance not authorized to be possessed by detainees or
health care personnel while performing their duties around detainees. This term also includes
any items or substances that can reasonable be expected to cause physical injury or adversely
affect the security, safety, and good order of the institution where detainees are present or the
custody and control of detainees. Contraband includes but is not limited to—
Guns and firearms of any type, their component parts (including ammunition clips or
magazines).
Explosives and ammunition.
Incendiary devices or mechanical and/or chemical components thereof.
Knives (including pocket knives).
Razor blades or blades of any type.
Currency (not carried on the person).
Intoxicants or alcoholic beverages.
Cellular phones and unauthorized radio transmitters.
Photographic equipment including film or digital cameras.
Printed material and video tapes that do not comply with the theater policy.
Recording devices (video or audio).
Extra clothing not worn or authorized at the job site.
Glass containers (unless approved by the MTF commander or the commander of the
internment/holding facility).
Metal fingernail files.
Weight-lifting dietary supplements (such as creatine).
Personally owned or retained handcuff keys.
8 November 2007
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A-1
Appendix A
Fraternize is to engage in social interaction with detainees beyond that necessary to perform
assigned duties. Fraternization includes, but is not limited to: dating, courting, flirting,
horseplay, personal friendships, and similar activities. Fraternization includes any act,
association, interaction, or relationship the circumstances of which are such as to lead a
responsible person to conclude that the good order and discipline or the custody and control
mission has been prejudiced.
Detainee is any person who is in US custody.
Security internee is any person who is detained for imperative reasons of security as
specified in the mandate set forth in the UN Security Council Resolution 1546.
High value detainees are security internees of significant intelligence or political value.
Former detainee is any person previously held as a detainee.
Gambling is participating in any game of chance for anything of value. Games of chance
include, but are not limited to: placing wagers on the outcome of the use of authorized
recreational equipment, sports events, or other events.
Knowingly is to act in a deliberate manner with awareness of the nature of one’s conduct.
Prohibited person is a detainee, former detainee, relative, or friend of a detainee or former
detainee or any other person acting on behalf of a detainee or former detainee.
Relative is a person connected with another by blood or by legal relationship (relationship by
marriage or adoption).
Sexual misconduct includes, but is not limited to: any acts or attempts to commit acts that
involve sexual contact, sexual abuse, sexual assault, or sexual harassment.
Sexual contact is the intentional touching, whether directly or through clothing, of a
person’s genitalia, anus, groin, breast, inner thighs, or buttocks with the intent to gratify the
lust or sexual desires of the person being touched or of the person touching.
Sexual abuse or assault includes, but is not limited to: forced or coerced sexual intercourse,
oral or anal sodomy, and sex with instruments.
Sexual harassment is verbal or physical sexual conduct that creates a hostile, offensive, or
intimidating work environment. This includes, but is not limited to, unwelcome sexual
advances, requests for sexual favors, and other verbal or physical conduct of a sexual
nature when: submission to or rejection of such conduct is made either explicitly or
implicitly a term or condition of a person’s job, pay, or career; submission to or rejection of
such conduct by a person is used as a basis for career or employment decisions affecting
that person; or such conduct interferes with an individual’s job performance or creates an
intimidating, hostile, or offensive environment.
SECTION II — RULES FOR APPROPRIATE INTERACTION BETWEEN
HEALTH CARE PERSONNEL AND DETAINEES
A-3. The provision of health care to detainees within MTFs or other facilities (such as dispensaries
located within internment or holding facilities) is a unique role within the military structure. This role is
governed by rules and regulations designed to ensure the provision of health care while ensuring personal
safety and maintenance of security, custody, and discipline in an internment/holding facility environment.
Health care personnel must ensure that their actions, both on- and off-duty, do not undermine their ability
to function effectively among detainees or compromise established health care, safety, security, and
custody guidelines.
RESTRICTIONS/LIMITATIONS
A-4. Health care personnel will not—
Fraternize with or act with undue familiarity towards a detainee, a former detainee, or a family
member of a detainee or former detainee. Any contact or communication (oral or written, direct
or mediated) between a health care worker and a detainee will be for an official purpose only.
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8 November 2007
Medical Code of Conduct in Detainee Operations
Place hands on or touch a detainee except in self-defense or to—
Prevent escape.
Prevent injury to persons or damage to property.
Render medical assistance.
Conduct a search or inspection for other than medical reasons.
Apply the priorities of force, as specified.
Demonstrate how-to procedures in training.
Visit or enter the personal space of a detainee, former detainee, or family member of a detainee
or former detainee except in the performance of official duties.
Engage in any act or attempt to engage in any act of sexual misconduct with a detainee, former
detainee, or family member of a detainee or former detainee.
Engage in any act or attempt to engage in any act of sexual abuse, assault, or harassment of a
detainee.
Knowingly allow a detainee to engage in sexual misconduct with another detainee.
A-5. Health care personnel are reminded that MP personnel have primary responsibility for security,
custody, and control.
A-6. The information in this appendix is not intended to limit health care personnel’s inherent authority
and obligation to take all necessary and appropriate actions to defend themselves, their units, and other US
Forces.
UNAUTHORIZED POSSESSION OF GOODS AND SERVICES
A-7. Unless specifically authorized in advance by the CDO, health care personnel, detainees and family
members of detainees will not—
Possess any items of contraband within the internment/holding facility or any MTF providing
medical care to detainees.
Accept from, give to, or exchange with a detainee, former detainee, or a family member of a
detainee or former detainee anything of value.
Accept gratuitously, as a gift or otherwise any service from a detainee, former detainee, or a
family member of a detainee or former detainee. Courtesy work of any nature or value (nominal
or otherwise) is not permitted.
Engage in any activity which constitutes gambling under this policy with a detainee, a former
detainee, or a family member of a detainee or former detainee.
Engage in any financial dealings, commercial transactions, or commercial activity with a
detainee, a former detainee, or a family member of a detainee or former detainee, including but
not limited to—
Obtaining a loan from or making a loan to a detainee, a former detainee, or a family
member of a detainee or former detainee, however negligible the amount.
Purchasing from or selling to a detainee, a former detainee, or a family member of a
detainee or former detainee, except in the performance of official duties.
Use their official position to secure unauthorized privileges or benefits for themselves or others,
including detainees, former detainees, or family members of detainees or former detainees.
Engage in unauthorized communications with detainees, former detainees, or family members of
detainees or former detainees. Health care personnel and detainees, unless specifically
authorized in advance by the MTF commander, DOMD, or the CDO, will not—
Write to, or accept correspondence from, a detainee, a former detainee, or a family member
of a detainee or former detainee, except in the performance of official duties.
Assist detainees in communicating with any other person via any channel which is not
authorized and subject to supervision or censorship.
8 November 2007
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A-3
Appendix A
Communicate via e-mail, chat rooms, or in any other manner with a detainee, former
detainee, or a family member of a detainee or former detainee, except in the performance of
official duties.
UNAUTHORIZED DISCLOSURE OF INFORMATION
A-8. Unless specifically authorized in advance by the MTF commander, DOMD, or the CDO, health care
personnel and detainees will not—
Review detainee medical or dental treatment files without having a clearly established and
official need to know. Information extracted from these files will be used only for official
purposes.
Discuss the following matters with a detainee, a former detainee, a family member of a detainee
or former detainee, the general public, or anyone else not having a need to know, except in the
course of official business:
Allegations of misconduct against any medical personnel.
Allegations of misconduct against any internment or holding facility personnel.
Recommendations of any individual board, panel, or hearing body and/or the vote of any
member of such entity.
Detainee mail, notes, or other written material of detainees.
Requests from former detainees for assistance in obtaining employment, including requests
for recommendations.
Any information from the medical or dental treatment records of a detainee or former
detainee. Only MTF personnel whose assigned duties include the disclosure of such
information may reveal such information.
Information concerning particular incidents, occurrences, disturbances, acts of misconduct,
or the handling of incidents involving detainees occurring at MTFs or at other facilities
located at detainee internment or holding facilities. Only the PAO should release
information regarding such incidents, upon approval by the MTF commander, DOMD,
internment or holding facility commander, or the CDO. Inquiries from the general public
should be referred to these officials.
Information concerning plans, operations, and procedures that are designed to maintain the
security, custody, or control of detainees, detainee internment or holding facilities, and the
security of MTFs that provide medical care to detainees.
MAINTAINING CUSTODY AND CONTROL
A-9. Unless specifically authorized in advance by the MTF commander, DOMD, or the commander of the
internment or holding facility, MTF personnel and personnel at units providing health care to detainees will
not—
Consume alcoholic beverages or other intoxicants of any kind during their normal tour of duty,
including mealtime. Personnel will discontinue consumption of alcoholic beverages sufficiently
in advance of scheduled tours of duty to avoid any impairment from full performance of their
assigned duties.
(Nothing in this appendix authorizes consumption of alcohol at any time, to the
extent that such consumption is prohibited by any other order, regulation, or directive.)
Allow a detainee or family member of a detainee to become uncontrolled or unsupervised. All
personnel providing medical care to detainees will coordinate at all times with assigned MP
security personnel to ensure detainee security, custody, and control.
Allow detainees assigned to a detail under their supervision to leave a medical care site without
valid authorization and appropriate supervision, custody, and control.
Condone, ignore, or overlook any misconduct by detainees. Medical personnel will
immediately correct any such misconduct, if possible and in any case, report actual or suspected
A-4
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8 November 2007
Medical Code of Conduct in Detainee Operations
detainee misconduct through the chain of command and to the MP personnel assigned to
provide security, custody, and control of detainees receiving medical care.
HOSTAGE SITUATIONS
A-10. Becoming a hostage while providing medical care to detainees, especially in an internment or
holding facility setting, is always a possibility. Personnel should remember if they find themselves in a
hostage situation that hostages—
Do not have any rank once they have been taken and they should not act as if they do. They
should avoid making demands or giving orders and should not give suggestions to their captors.
Should listen carefully for clues regarding the emotional state of the detainees who have taken
them hostage.
Should remain calm and alert; and they should not become aggressive.
Should avoid political or religious discussions.
Should not make any promises that they cannot fulfill.
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A-5
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Appendix B
Detainee Behavioral Health Care
This appendix discusses the minimum standards for integrating the mandates of the
Geneva Conventions and AR 190-8 for detainee BH care. The components of these
mandates include standards, training, services, resources, staffing, and cross-cultural
compatibility.
COMPONENTS
B-1. The Geneva Conventions and AR 190-8 established the foundation, or minimum standards, for
detainee BH care. These standards and expected practices establish Level I of a three-level model (see
Table B-1). Internment facilities may adopt Level II or III to meet their custodial objectives. These
include—
Level I that is based on standards and expected practices corresponding to the Geneva
Conventions and AR 190-8.
Level II that contains Level I and is based on the remaining mandatory standards and expected
practices. Level II standards exceed the Geneva Conventions and AR 190-8 requirements and
satisfy the standards and expected practices deemed essential.
Level III that contains Level II and nonmandatory performance standards and expected
practices. Level III standards exceed the Geneva Conventions and AR 190-8 requirements and
satisfy all BH requirements.
Table B-1. Continuum of health care standards and expected practices
Level I
Level II
Level III
Access to Care
Access to Care
Access to Care
Clinical Services
Clinical Services
Clinical Services
Continuity of Care
Continuity of Care
Continuity of Care
Referrals
Referrals
Referrals
Transportation
Transportation
Transportation
Treatment Plan
Treatment Plan
Treatment Plan
Emergency Plan
Emergency Plan
Emergency Plan
Infirmary Care
Infirmary Care
Infirmary Care
Pregnancy
Pregnancy
Pregnancy
Management
Management
Management
Health Screens
Health Screens
Health Screens
Health Appraisal
Health Appraisal
Health Appraisal
Periodic Examinations
Periodic Examinations
Periodic Examinations
Behavioral Health
Behavioral Health
Behavioral Health
Program
Program
Program
Behavioral Health
Behavioral Health
Behavioral Health
Screen
Screen
Screen
Behavioral Health
Behavioral Health
Behavioral Health
Appraisal
Appraisal
Appraisal
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B-1
Appendix B
Table B-1. Continuum of health care standards and expected practices (continued)
Level I
Level II
Level III
Behavioral Illness and
Behavioral Illness and
Behavioral Illness and
Developmental
Developmental
Developmental
Disability
Disability
Disability
Pharmaceuticals
Pharmaceuticals
Pharmaceuticals
Suicide Prevention and
Suicide Prevention and
Intervention
Intervention
Detoxification
Detoxification
Chronic Care
Chronic Care
Health Education
Behavioral Health
Evaluations
Management of
Chemical Dependency
B-2. Training is critical to effective correctional operations. Medical staff, BH staff, and custodial staff
must undergo initial (or orientation) training, as well as ongoing training to keep their skills honed. See
Table B-2 for staff training standards and expected practices. See Table B-3 for humane treatment
standards and expected practices.
Table B-2. Staff training standards and expected practices
Level I
Level II
Level III
Health Authority
Health Authority
Health Authority
Provision of Treatment
Provision of Treatment
Personnel
Personnel
Qualifications
Qualifications
Credentials
Credentials
Emergency Plans
Emergency Plans
Emergency Response
Emergency Response
Employee Orientation
Table B-3. Humane treatment of detainees standards and expected practices
Level I
Level II
Level III
Segregation
Segregation
Segregation
Research
Research
Research
Use of Restraints
Use of Restraints
Use of Restraints
Confidentiality
Confidentiality
Informed Consent
Informed Consent
Involuntary
Involuntary
Administration
Administration
Grievances
Notification
Special Needs
Privacy
Transfer
Sexual Assault
B-3. Specific services correspond to each level of the detainee BH care program. For example, at Level I
services include initial intake assessments, crisis intervention, BH appraisal, daily sick call, brief
B-2
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Detainee Behavioral Health Care
counseling, stabilization/acute hospitalization, special BH evaluations, and staff consultation. Levels II
and III build on Level I services and broaden the scope of care. See Table B-4 for the services by level.
Table B-4. Services by level
Level
Program Services
Description
I
II
III
Initial screening
Brief interview during inprocessing or intrafacility transfer; BH
X
X
X
assessment
services information given.
In-depth assessment of suicide, violence, sexual-victimization,
Appraisal
X
X
X
predatory behaviors, and substance abuse risks.
Crisis intervention
X
X
X
Around-the-clock emergency response services.
Sick Call
X
X
X
Daily triage services.
Brief counseling
X
X
X
One to four sessions focused on a specific stressor or problem.
Stabilization/acute
X
X
X
Around-the-clock emergency stabilization.
hospitalization
Specialized testing of severely mentally ill and developmentally
Special BH evaluations
X
X
X
disabled detainees. Assessment for legal/administrative issues.
Maintenance of BH
X
X
X
Documentation of BH care as required by SOPs.
records
Consultation
X
X
X
Interactive education of custodial staff.
Behavioral health staff is notified when detainee is transferred to
Segregation monitoring
X
X
X
segregation. Detainee receives daily BH visits.
Specific focus on pregnancy testing, prenatal care, and emotional
Pregnancy management
X
X
X
support.
Medication evaluation
X
X
X
Medication evaluation and treatment.
Elective in-depth therapy aimed at significant change in behavior,
Individual psychotherapy
X
X
emotions, or attitudes.
Educational training in suicide risks and warning signs. Staff
Suicide prevention and
X
X
X
training in suicide watch procedures. Protocols for detainee
intervention
follow-up. Traumatic event debriefings for staff and detainees.
Substance detoxification
X
X
Medically supervised substance detoxification.
Detainees with behavioral disorders are managed from admission
Case management
X
X
to transfer or discharge.
Special therapies for specific BH issues (for example: torture,
Specific treatment groups
X
X
posttraumatic stress disorder, substance abuse, or self-mutilation)
Transitional care services
X
X
Partial hospitalization services.
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B-3
Appendix B
Table B-4. Services by level (continued)
Level
Program Services
Description
I
II
III
Educational classes
X
Ongoing program of health education and wellness information.
Chemical dependency
Standardized diagnostic needs assessment tools; multidisciplinary
X
program
treatment team; and abuse risk assessments.
Sexual assault evaluation
Forensic evaluation after sexual assault; clinical assessment and
X
and treatment
treatment.
Vocational and
Inclusion of occupational and activity therapists in detention
X
educational programs
facility’s academic and vocational training programs.
Residential care services
X
Long-term hospitalization services.
B-4. Detainee BH care requires adequate resource support. Infirmary services, in particular, demand
considerable resources to ensure a safe environment for staff and patients. The inpatient psychiatric ward
is equipped with 0.5 to 1 psychiatric patient bed for every 100 detainees. See Table B-5 for performance
improvement standards and expected practices.
Table B-5. Performance improvement standards and expected practices
Level I
Level II
Level III
Statistical Reports
Statistical Reports
Statistical Reports
Internal Review and
Internal Review and
Internal Review and
Quality Assurance
Quality Assurance
Quality Assurance
Staffing
Staffing
Staffing
Health Records
Health Records
Health Records
Peer Review
Peer Review
Transfers
Inactive Records
B-5. The staffing model is a function of number of patients, staff-to-patient ratios, and model level.
Nurse-to-patient bed ratios guide staffing requirements for the inpatient psychiatric ward of the infirmary.
B-6. The Detainee Behavioral Health Care Program is compatible with all cultural beliefs. Cultural
beliefs about mental illness were identified in psychiatric literature and compared with the program model.
These beliefs did not necessitate modification of the model itself. This cross-cultural information,
however, was readily applicable to clinical understanding of the nuances of patient presentation (access to
care) and pathology and to therapeutic techniques. Cross-cultural training is important for all clinicians.
The most important aspects of cultural factors affecting clinical care are discussed in Table B-6.
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Detainee Behavioral Health Care
Table B-6. Cross-cultural clinical considerations
Category
Information
Patients may delay seeking treatment for months or even years and are disappointed upon
seeking treatment as a result of cultural beliefs surrounding mental illness.
In certain areas of the world, the word madness is often associated with possession and
sorcery and some precipitating factors are considered to be intimately linked to social
relationships.
Stigma and
Attitudes towards mental illness have no relationship with age, educational level, marital
Barriers to Care
status, gender, and personal exposure to people with mental illness.
Even among the well-educated (including physicians), many people are more likely to
believe that spirits are the primary cause of mental illness, not genetic factors.
Supernatural explanation seems to be too deeply imprinted during upbringing to be erased
by education and beliefs surrounding cause of symptoms may dissuade or impede persons
from seeking medical assistance.
Trust is important to all patients.
Patients may not trust the interviewers (therapists), may fear that confidentiality will be
breached, and may be reluctant to share personal information with either the interviewers or
the interpreters.
Therapist-
Clinicians may be uncomfortable with the potential torture and/or trauma experienced by
Patient
detainees and may avoid asking related questions.
Relationship
Clinicians should declare an open commitment to supporting human rights, while at the
same time remaining objective.
By avoiding overidentification with the patients, clinicians will be more likely to ask difficult
questions that will aid in both diagnostic assessment and treatment.
Posttraumatic stress disorder (or syndrome) model is a useful conceptual and therapeutic
approach to the psychological impact of trauma on patients from other ethnocultural
Diagnostic
backg2rounds.
Considerations
Traumatized patients frequently have multiple somatic complaints, severe depression, or
dissociative and paranoid symptoms.
The clinician must be careful to elicit a trauma story at the pace dictated by the detainee.
A medical practitioner may have the advantage over a nonmedical psychotherapist because
a medical approach is familiar to detainees.
Proceed at a slow pace, especially as the trauma story unfolds.
Medication may be useful in reducing the severity of intrusive and hyperarousal symptoms,
allowing the therapeutic process to proceed more effectively.
Grief over loss of status, money, friends, family, as well as over other losses is often a
central theme in the therapeutic process.
Self-worth is often seriously damaged and issues related to the meaning of life and religion
are often in the foremost of their minds.
Treatment
Risk for retraumatization is high.
Considerations
Group therapy diminishes a sense of isolation and learning that others have a similar
experience is beneficial.
At all stages, careful explanation and education is required.
Anything resembling interrogation should be avoided.
Retelling the trauma story is a common element in therapy and is independent of any
particular theoretical orientation.
Cognitive restructuring is another common therapeutic theme as are homework, oral/written
testimony of the experience, medication, stress management, and relaxation techniques.
Family and group assume greater importance and may be needed in therapy.
Use of traditional approaches, when combined with Western approaches, may be helpful.
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B-5
Appendix B
Table B-6. Cross-cultural clinical considerations (continued)
Category
Information
Interpreters should not act merely as translators, but as culturally appropriate and
empowered agents operating with the therapist allowing a clearer understanding of both
verbal and nonverbal communication and evaluating the cultural significance of what is
being said.
Interpreters
Bilingual interpreters can overidentify with patients and may have difficulty maintaining
appropriate professional distance. If the bilingual interpreter has a role expectation beyond
that of interpretation, such as a culture broker or paraprofessional, these issues remain
potentially troublesome.
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Appendix C
Medical Inprocessing Screening Tools
This appendix provides three medical inprocessing screening tools. These sample
formats can be preprinted on the SF 600 to facilitate detainee medical inprocessing to
the TIF.
PHYSICAL EXAMINATION
C-1. The inprocessing physical examination begins with a review of all systems. Figure C-1 provides a
sample inprocessing format which may be overprinted on the SF 600. This overprint provides a flexible
tool which will facilitate a standardized inprocessing medical screen.
BEHAVIORAL HEALTH INPROCESSING SCREENING
C-2. As discussed in Chapter 4, detainees inprocessing to the TIF should undergo a BH screen. This
screening is documented and included in the detainee’s individual medical record. Figure C-2 provides a
sample BH screening checklist which can be used to document the screening.
QUALITY ASSURANCE SCREEN
C-3. Upon completion of the medical inprocess screening, a quality assurance check of the medical record
is accomplished to ensure the detainee has completed all of the requirements and that the documentation is
in order. Figure C-3 provides a sample checklist for ensuring the completeness of the medical screening
process.
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C-1
Appendix C
Figure C-1. Inprocessing overprint for Standard Form 600
C-2
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Medical Inprocessing Screening Tools
Figure C-1. Inprocessing overprint for Standard Form 600 (continued)
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C-3
Appendix C
Figure C-1. Inprocessing overprint for Standard Form 600 (continued)
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Medical Inprocessing Screening Tools
Figure C-2. Sample behavioral health screening tool
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C-5
Appendix C
Figure C-3. Quality assurance checklist tool
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Appendix D
Preventive Medicine Inspection Checklist
This appendix provides a sample internment facility inspection checklist (Table D-1)
for use when inspecting a DCP, DHA, or TIF.
Table D-1. Sample internment facility inspection checklist
Preventive Medicine Inspection Checklist
Yes
No
Definitions: Short-term: Up to 5 days anticipated use.
Long-term: Over 5 days up to 45 days anticipated use.
Temporary: No permanent or semipermanent construction such as guard towers or permanent fencing.
Example: a DCP or DHA
Name
Facility
Building
Location
OIC/NCOIC
Telephone number or other contact information
Unit
Higher Headquarters
Type Facility: Short-term temporary __________
Long-term temporary ___________
Except as noted, requirements are the same for both type facilities.
Location
Camp Size. Adequate area is available for camp?
Note. Estimated requirement of 320 square feet per person which equates to 37 acres for a 5,000-person camp. (1 Acre =
43,560 square feet; 37 Acres = 1,611,720 square feet. For reference 37 acres is approximately 1,270 feet by 1,270 feet
square)
Sleeping
Are adequate sleeping areas provided?
Note: Covered living space should provide a minimum of 40 square feet per person with an optimum requirement of 80 square
feet per person. Beds or mats should be separated by a minimum distance of 2.5 feet.
If both male and female detainees, are separate facilities provided?
Clothing
Is adequate clothing provided?
Is clothing suitable for environment, heat, cold, exposure to sun and wind?
If required by command surgeon, is clothing pretreated with permethrin?
Clothing available should be 110 percent of the camp population and of a variety of sizes to allow for weekly
exchange of clothing. Is exchange clothing provided while detainees are washing their clothing?
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D-1