R432-152-29. Client Records

(1) The facility shall develop and maintain a record keeping system that includes a separate record for each client with documentation of the client's health care, active treatment, social information, and protection of the client's rights.

(a) The facility shall keep confidential all information contained in the client's records, regardless of the form or storage method of the records.

(b) The facility shall develop and implement policies and procedures governing the release of any client information, including consents necessary from the client or client's legal guardian.

(c) All entries into client records must be legible, dated and signed by the individual making the entry.

(d) The facility shall provide a legend to explain any symbol or abbreviation used in a client's record.

(e) The facility shall insure each identified residential living unit has available on-site pertinent information of each client's record.

(f) Client's records shall be complete and systematically organized according to facility policy to facilitate retrieval and compilation of information.

(2) The client record department shall be under the direction of a registered record administrator, RRA, or an accredited record technician, ART. If an RRA or ART is not employed at least part time, the facility shall consult at least semi-annually with an RRA or ART according to the needs of the facility.

(3) Client records shall be safeguarded from loss, defacement, tampering, fires, and floods.

(4) Client records shall be protected against access by unauthorized individuals.

(5) Client records shall be retained for at least seven years after the last date of client care.

(a) Records of minors shall be retained as follows:

(i) at least two years after the minor reaches age 18 or the age of majority; and

(ii) a minimum of seven years.

(b) All client records shall be retained within the facility upon change of ownership.

(c) If a facility ceases operation, provision shall be made for appropriate safe storage and prompt retrieval of all client records, client indices, and discharges for the period specified.

(d) The facility may arrange storage of client records with another facility or may return client records to the attending physician who is still in the community.