R03-603 Client Case Records

A. A licensee shall ensure that a current active client record is maintained for each client and:

1. Is protected at all times from loss, damage, or alteration,

2. Is confidential and released only as provided in R03-602,

3. Is legible and recorded in ink or electronically recorded,

4. Contains entries that record the date and time of service and are:

a. Signed by the individual making the entry, or

b. Initialed by the individual making the entry, or

c. Authenticated by the individual making the entry in accordance with the following:

i. The individual who makes the entry uses a computer code,

ii. The computer code is not authorized for use by another individual, and

iii. The individual who makes the entry signs a statement that the individual is responsible for the use of the computer code,

5. Is available for review during the provider's hours of operation or at another time agreed upon by the provider upon written request by the client or the client's parent, guardian, or designated representative, if applicable, unless:

a. The program director or designee determines that the client's review of the client record is contraindicated and documents the reason for the determination in the client record, and

b. A client chooses to submit a grievance to the program regarding the decision not to grant the client’s review of the client record,

6. Does not contain identifying information about another client according to 42 CFR, Part 2,

7. Is current and accurate,

8. Is amended as follows:

a. The information to be amended is struck out with a single line that allows the struck information to be read, and

b. The amended entry is signed, initialed, or authenticated as described in subsection (A)(4)(c) by the individual making the amended entry,

9. Except as provided in subsection (A)(10), contains original documents and original signatures, initials, or authentication,

10. For events occurring during group counseling, may contain photocopies of original documents with client specific treatment information added,

11. Is available and accessible to staff members who provide treatment services to the client,

12. Is retained after a client's discharge for six years after the date of the client's discharge, unless otherwise provided by law or these standards,

13. Is disposed of in a manner that protects client confidentiality.

2. Verify each release in client’s file has all 8 elements of R03-602 D completed. 3. Review policy and procedure manual and verify in client files. 4. Review policy and procedure manual regarding HIPPA compliance of Personal Health Information. Review and verify computer code list assignments, examples passwords, program codes. Verify signed statement in employee files. 6. Verify by reviewing client files.

 

B. A licensee shall ensure that a client record contains the following:

1. The client's name, address, home telephone number, and date of birth,

2. The name and telephone number of:

a. An individual to notify in case of emergency,

b. The client's medical professional,

c. The individual who coordinates the client's treatment services or ancillary services, and d. The client's parent, guardian, or designated representative,

3. The date the client was admitted into the program,

4. The following information about each referral made or received by the provider:

a. The date of the referral,

b. The reason for the referral, and

c. The name of the entity, provider, program, or individual that the client was referred to or from,

5. If the client is involuntarily committed, a copy of the court orders, if available,

6. Documentation of consent to treatment,

7. Documentation signed and dated by the client indicating receipt of the information required to be provided under R03-601 (A), receipt of HIV transmission and high risk behavior information, and infectious pulmonary tuberculosis ,

8. The client's written consent to participate in research or treatment that is not a professionally recognized treatment according to R03-203 (I)*, if applicable,

9. The assessment information and updates to the assessment information,

10. The treatment plan and updates and revisions to the treatment plan,

11. Information or records provided by or obtained from another individual, agency, program, or entity regarding the client, as applicable,

12. Documentation of authorization to release a client record or information, if applicable,

13. Documentation of:

a. requests for client records and of the resolution of those requests,

b. release of the client record, or

c. information from the client record to an individual or entity,

14. Documentation of telephone, written, or face-to-face contact with the client or another individual that relates to the client's health, safety, welfare, or treatment,

15. Documentation of:

a. Assistance provided to a client who does not speak English,

b. Assistance provided to a client who has a physical or other disability, and

c. A client's general medical condition,

16. Documentation of treatment services provided to the client, according to the client's treatment plan,

17. Documentation of medication services or the self-administration of medication if applicable,

18. Date of discharge and the discharge summary, if applicable,

19. If the client is receiving treatment in a residential program, documentation of the client's:

a. Orientation to facility,

b. Presence and participation in program for each 24 hour day,

c. Screening for infectious pulmonary tuberculosis, and

d. Nursing assessment or physical examination, if applicable, and

e. Medical orders, if applicable.

20. Copies of all consultation reports, and

21. Medication information including the:

a. Type of medication,

b. Dosage,

c. Frequency of administration,

d. Route of administration, and

e. Staff member who monitors the medication administration or self-administration.

Review client file and verify all elements of R03-603 1-21 are in the file. *I is an incorrect reference, please refer R03-203 (J).