R501-19A-9. Client Records

(1) The provider shall maintain a process for the retention of any client record for seven years or until a client turns 21 years old, whichever comes later. (2) The provider shall make any client record available to OL upon request. (3) The provider shall ensure each client record includes: (a) the client name, date of birth, and identified gender; (b) accurate parent or legal guardian contact information; (c) a list of any client's authorized contact as identified by the client's parent, legal guardian, or sending agency or private agency, including each authorized contact's: (i) name; (ii) phone number; and (iii) relationship to the client; (d) any signed agreement and consent form; (e)(i) consent for each treatment and non-clinical service signed by the client, or the client's parent or legal guardian; or (ii) a court order of commitment to services in lieu of signed consent for each treatment and non-clinical service; (f) any information that could affect the health, safety, or well-being of the client, including any: (i) allergy; (ii) chronic condition; (iii) communicable disease; and (iv) medication needs; (g) any grievance or complaint made by or against the client and any action taken by a provider; (h) each crisis intervention or critical incident report involving the client; (i) an individualized assessment for restriction of access to any on-site item that could be used as a weapon, for self-directed violence, or as an intoxicant; (j) an individualized disruption plan; (k) an individualized suicide prevention plan, as needed; (l) an intake screening and assessment; (m) any progress note and service provided with date and signature of staff completing each entry; (n) a summary of attendance and absence in each treatment service; (o) the treatment or service plan; (p) any referral arrangement made by the provider; (q) discharge documentation; and (r) an initial and annual client tuberculosis screening result for any client with a history of substance abuse. (4) The provider shall disclose how any client and client's parent or legal guardian may access any educational or medical record following the client's discharge from the program, including how and where to locate records if the program is no longer licensed.