TITLE:Uniform Client Records

POLICY AND PROCEDURE

House of New Hope

POLICY: CR-800

TITLE:Uniform Client Records

EFFECTIVE DATE: January 1, 2008AUTHORIZED BY: Board of Trustees

REVISION DATE: 3/2015, 5/2016

POLICY:HONH shall maintain a uniform client records system and a written electronic client record on each client receiving face-to-face mental health services. The client records of the persons served communicates information in a manner that is organized, clear, complete, current, and legible. The clinical record for each client shall be maintained in such a manner as to protect the client’s confidentiality.

PROCEDURE:

1.All documents generated by HONH that require signatures shall include an original or electronic signature.

2.The client record contains identifying information on standardized forms. The following identifying items are included in all client records:

a.Date of admission;

b.Information about the client’s personal representative, conservator, guardian, or representative payee, if any of those have been appointed, including the name, address, and telephone number;

c.Emergency contact person, their name, address, and telephone number;

d.The person who is currently coordinating the client services;

e.Location of other records as applicable;

f.The client’s primary care physician, including name, address, and telephone number, when available;

g.Healthcare reimbursement information, if applicable;

h.Client’s health history;

i.Current medications;

j.Preadmission screening, when conducted;

k.Documentation of orientation;

l.Assessments;

m.Individual plan, including reviews;

n.Treatment details;

o.Progress notes;

p.Correspondence pertinent to person served;

q.Authorization for release information;

r.Documentation of internal and external referrals.

3.HONH does not maintain duplicate files.

4.All entries into the records of the person served follow HONH’s policy that specifies time frames, which are as follows:

a.Admission notes within 15 days.

b.Assessments within 30 days of admission.

c.Individual Plans within 30 days of admission.

d.Progress notes filed within 7 days of contact to be completed within 24 hours of contact.

e.Discharge Summary within 30 days of discharge for mental health and 10 days for foster care.

5.The client is asked to sign the individual plan as a way of verifying his/her participation in the process. The client’s response to the individual plan is also noted in a Progress Note.

6.The Discharge Summary is included in the client’s record within 30 days following discharge from the facility. The Discharge Summary shall include the date of admission, presenting condition, describe the extent to which stabilized goals and objectives were achieved, the services provided, the reasons for discharge, the status of the client at discharge, lists recommendations for services or supports, the date of discharge from the program, and a Transition Plan, when applicable.

7.HONH adheres to specific policies and procedures relevant to the compilation, storage, dissemination, and accessibility of client records.

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