Community Services Programs

Mental Health Agency Licensing Standards; Agency Managemnet - Client Records

REC.1
The agency shall maintain client records in a manner that provides security.

REC.1.A.
Client records are stored in secure areas such as locked file cabinets.

REC.1.B.
Automated record keeping systems have restricted access through access codes or other automated security measures.

REC.1.B.1
There is a back-up system for all automated client records.

REC.1.C.
The agency has a policy and procedure regarding personnel who are authorized to have access to records that is in compliance with federal, state and local laws.

REC.1.D.
There is a method for documenting when records are accessed and taken from the area where they are stored (i.e., outguides, logs). This method should minimally document the person's name, title or relation to the client, date and time taken and returned.

REC.1.E.
There are no substantiated complaints of breaches of confidentiality that result from improper records management. All substantiated complaints will be assessed for the seriousness of the violation and actions taken to achieve compliance.

REC.2
Client records shall contain identifying information sufficient to describe the client's background, resources, and need for treatment.

REC.2.A.
Records should minimally contain the following information about the client:

REC.2.A.1
full name;

REC.2.A.2
address;

REC.2.A.3
phone number(s);

REC.2.A.4
date of birth;

REC.2.A.5
gender;

REC.2.A.6
unique client identifier;

REC.2.A.7
income and financial resources;

REC.2.A.8
next of kin or other contact person;

REC.2.A.9
occupation;

REC.2.A.10
current school and grade level or highest level achieved;

REC.2.A.11
family composition;

REC.2.A.12
marital status

REC.2.A.13
living arrangement outside the agency, if applicable;

REC.2.A.14
prescription and over-the-counter medications used previously and currently;

REC.2.A.15
allergies and drug reactions.

Interpretive Guideline for REC.2.A. through REC.2.A.15
Emergency services shall provide documentation of as many of the above elements as possible.

REC.2.B
When the client is a minor or ward, the record should also include: the name, address and phone number of the legally responsible parent, guardian or custodian.

REC.3
All documents or entries in the client record shall be legible, dated and signed by the person making the entry, written in ink or typed, and properly corrected as necessary.

Interpretive Guideline for REC.3
"Properly corrected" is interpreted to mean that errors are voided by crossing out the incorrect entry with one line, writing "void" next to the crossed out entry, and initialing and dating the correction. Although writing "error" is acceptable, most attorneys/risk managers suggest that agencies avoid writing "error" in client records. White out shall not be used to correct errors in client records.
Signature stamps are only allowed for individuals with handicapping conditions and when a written agency policy and procedure on the use of signature stamps is present.

REC.4
The agency has a documented internal record review process that periodically determines and improves compliance with these standards and other policies and procedures the agency may develop.