Client records

1. A program shall prepare and maintain a single record for each client admitted to the program so as to communicate the appropriate case information. This information must be in a form that is clear, concise, complete, legible, and current. 2. A program shall implement a written policy addressing the process by which a client may gain access to the client's own record. 3. If duplicates of information or reports from the single record of a client exist or if working materials are maintained, such material must: a. Not be a substitute for the single record; b. Be secondary to the recording of information with the single record of the client receiving first priority; and c. Record information of value to the specific service, such as daily attendance, raw scores of tests, and similar data. 4. A program must apply appropriate safeguards to protect active and closed confidential written, electronic, and audiovisual records and to minimize the possibility of loss or destruction in the following manner: a. The information in active and closed records must be organized in a systematic fashion. Manual systems must provide for affixing active records to record jackets; b. The location of the records of clients and the nature of the information contained therein must be controlled from a central location; c. A program employee must be responsible for the control of records of clients and for the implementation of the policies pertaining to records of clients; d. Access to records of clients and electronically generated documents must be limited to the members of the professional staff who are providing or supervising direct services to the client and such other individuals as may be administratively authorized; e. The program must maintain an indexing and filing system for all manual and electronic records of clients; f. The program must secure records and take reasonable steps to protect the records against fire, water damage, and other hazards; g. The program must follow routine procedure for backup of data files for electronic systems; and h. The program must implement a policy that defines file access control procedures. 5. Client records must include: a. Identification data; b. The name and address of the legal representative, conservator, guardian, and representative payee of the client; c. Pertinent history, a diagnostic assessment on all five axes of the DSM, a six-dimension assessment of the current version of the ASAM patient placement criteria, disability, presenting need, functional limitation, client strengths, and desired outcomes and expectations; d. Prescribed medications; e. Relevant medical information; f. Reports of assessment and individual treatment planning; g. Signed and dated progress notes describing in measurable and behavioral terms the client's progress toward the attainment of the client's treatment plan objectives; h. Reports from referring sources; i. Reports of service referrals; j. Reports from outside consultants; k. Designation of the case manager, licensed addiction counselor, and other staff for the client; l. Evidence of the direct involvement of the client in the decisionmaking process related to the client's program; m. Reports of team conferences; n. Reports of family conferences; o. The individual plan of the client, including the overall plan and the plans for specific services and signature of the client or other documentation of the client's involvement in the plan; p. References to audiovisual records; q. Correspondence pertinent to the client; r. Signed and dated release forms; s. Transfer summary describing in measurable and behavioral terms a client's move from one level of care to another; t. Discharge summary describing in measurable and behavioral terms the client's progress and attainment of treatment plan goals and criteria for discharge. When the client is transferred, the discharge summary must include a discharge plan which identifies the treatment goals not yet achieved as well as any problems that have been deferred for treatment by a subsequent provider; and u. If admission, ongoing care, or discharge criteria as described by the department have not been met, the provider must document the grounds for placement, ongoing care, or discharge decisions. 6. A program shall implement a written policy that specifies time frames for entries into the records of a client, such as clinical information, critical incidents or interactions, progress notes, and discharge summaries. A program must enter progress notes into client records according to the following schedule: a. Shift entries for inpatient clients; b. Daily entries for clients in day treatment; c. Weekly entries for intensive outpatient clients; d. Weekly entries for clients in outpatient services seen once or more a week but monthly for those clients seen less than once a week; e. Weekly entries for clients in clinically managed high-intensity residential care; and f. Monthly for clients in clinically managed low-intensity residential care.