Section 325.14910. Client records; content; maintenance.

(1) There shall be a case record for each client. All of the following items shall be filed in the case record, if applicable:

(a)     Results  of  all  examinations,   tests,  and  other    assessment information.

(b)   Reports from referring sources.

(c)   Treatment plans.

(d)  Records of referrals to outside resources.

(e)    Reports from outside resources, which shall include the name of the resource and the date of the report. These reports shall be signed by the person who makes the report or by the program staff  member who receives the report.

(f)  Case conference and consultation notes, including the date of the conference or consultation, recommendations made, and actions taken.

(g)   Correspondence related to the client, including all  letters  and dated notations of  telephone  conversations  relevant  to  the  client's treatment.

(h)   Treatment consent forms.

(i)   Information release forms.

(j)    Progress notes. Entries shall be filed in chronological order and shall include the date any relevant observations were made, the date the entry was made, and the signature and staff title of the person who  makes the entry.

(k)     Records of services provided. Summaries of services provided shall be sufficiently detailed so that a person who is  not   familiar  with  the program can identify

the  types  of  services  the   client  has  received. General terms such as "counseling" or "activities"  shall be avoided in describing services.

(l)   Aftercare plans.

(m)   ) Discharge summary.

(n)   Follow-up information.

(2)   A program shall provide sufficient facilities for the storage, processing, and handling of client case records. These facilities shall include suitably locked and secured rooms and files.

(3)   Appropriate records shall be readily accessible to those staff members who provide services directly to the client.

(4)   Client case records shall be maintained for not less than 3 years after services are discontinued.

(5)   If a program stores client data on magnetic tape, computer files, or other types of automated information systems, security measures shall be developed to prevent inadvertent or unauthorized access to data files.

History: 1981 AACS.