RECORDS MANAGEMENT / RETENTION

RECORDS MANAGEMENT / RETENTION

POLICY    Close safeguards have been implemented to insure the protection of the client’s Personal Health Information. The Ship Group Community Services has in addition to protecting the contents of clients’ records, provided guidelines for secure storage, transporting, records availability, records retention and records disaster recovery. Clients and their legally responsible persons will be provided with the Consent for Disclosure of Confidential Information Form during Pre-Screening or at Intake through the program’s Intake Packet. The Client and/or the legally responsible person’s signature on these documents will acknowledge the authorizations needed to release information to those with a need to know. In addition to client records, the program is responsible for confidentially maintaining personnel files, including their confidential medical and legal records. All program records, files, and documentation will be maintained for no less than five years. To every extent possible client, staff, and program records will be filed electronically and the electronic file maintained at an off-site storage agency, one year following inactivity. Electronic back-up disks with computer programs and documentation will also be stored off-site, to avoid a lapse in service in the event of a disaster. Back-up hard copies of files pertinent to the program’s daily operations will also be maintained off-site, as a matter of providing quality assurance for the on-going business of The Ship Group Community Services , LLC.

PERSONS AUTHORIZED TO DOCUMENT

The following staff members are authorized to document in the client’s records:

• Medical Director
• Clinical Director
• Licensed Professional
• Para-professionals/Peer Support Specialists
• Program Directors
• Qualified Professionals
• Associate Professionals
• Clinical Psychologist
• Program Nurse
• Client’s Physician
• Administrative Assistants, under the direction of the Program Director/Coordinator, demographic information and changes only

Volunteers, students, nor advocates may document in the client record, except by authority of the Clinical Director. The program will accept information in written form from the aforementioned individuals addressed to the Medical Director, Program Director, or the Clinical Director, who will determine how or if such information will be added to the client record.

Staff persons are required to document with privacy and confidentiality in mind. Client files must never be left out and therefore, made readily accessible and staff closets, offices, and files must be locked at all times. Staff are instructed to keep keys on wrist rings or on their person at all times.

TRANSPORTING CLIENT RECORDS

When transportation of client records is necessary, the on-duty staff shall use the following procedure:

1. The records shall be enclosed in a large manila envelope;

2. The envelope shall be placed in the agency briefcase and locked;

3. If a trunk is available, place the briefcase in the trunk;

4. If no trunk is available, the briefcase should be as close to the staff person as possible in the transportation.

5. The client records shall only be removed from inside the briefcase once inside the intended office or healthcare agency;

6. The client records must never be given to a client or to a non-employee of The Ship Group Community Services to transport or for any other reason;

7. All data received from a physician, regarding the client, shall be copied and the original (except prescriptions) will be maintained in the client’s file. In reference to The Ship Group Community Services Care programs that participate in medication administration, a copy of the prescription will be placed in the client file before it is taken for dispensing.

Emergency information for each client of The Ship Group Community Services is kept in the crisis book/crisis plan for immediate availability. The emergency information is also kept in an envelope inside a locked briefcase.

Staff are not permitted to document client information on their personal portable computers. ONLY AGENCY COMPUTERS ARE TO BE USED FOR ANY CLIENT PERSONAL HEALTH INFORMATION.

Staff found in violation of this policy will be disciplined and/or discharged and their name added to the North Carolina Healthcare Personnel Registry for violating client rights.

CLIENT RECORDS: CONFIDENTIALITY AND SECURITY

The client’s original documentation (Master File) is maintained in locked files in the Administrative Offices of The Ship Group Community Services Copies of information necessary for the client’s treatment are maintained at the agency. A Master File is maintained in the Administrative Office, which is complete with all required data. A minimum of fourteen days of original service/progress notes are maintained in the client’s master file in the Administrative Offices.

ALTERATION IN THE CLIENT RECORD

A client or a client’s legally responsible person may contest the accuracy, completeness, or relevancy of information in the client record and may request alteration of such information. Alterations shall be made as follows:

• Whenever a clinical staff member concurs that such alteration is justified the area agency shall identify the contested portion of the record and allow a statement relative to the contested portion to be added to the record which shall be recorded on a separate form (Clinical Addendum Form) and not on the original portion of the record;

• Whenever a clinical staff member does not concur that an alteration is justified, all statements made shall be made a permanent part of the client’s record and shall be released or disclosed along with the contested information.

ASSURANCE OF CONFIDENTIALITY OF RECORDS

All employees and volunteers sign an Assurance of Confidentiality Form prior to being given any access to client information. Prior to signing the form, the Director will make known to those with access to confidential information the provision of the rules in Subchapter GS 122C-52 through 122C-56. Individuals indicate an understanding of the requirements governing confidentiality by signing a statement of understanding and compliance. Employees will sign a statement upon employment and again whenever revisions are made in the requirements. The Statement of Acknowledgement of Confidentiality contains the following information:

• date and signature of the individual and his title;

• name of area or state facility;

• statement of understanding;

• agreement to hold information confidential; and

• acknowledgement of civil penalties and disciplinary action for improper release or disclosure.

All students, volunteers, and other individuals with access comply with the rules in Subchapter GS 122C-52-122C-56.

Corrective Action Plans will be issued to staff that violate client confidentiality, up to and including discharge.

TO AVOID TAMPERING WITH CONFIDENTIAL RECORDS

All files are kept secure in the administrative offices. Unauthorized persons are not allowed access to client records or program data of any kind. The Program Director ensures that a clinical staff member is present in order to explain and protect the record when a client or a client’s legally responsible person comes to the office to review the client record. A delegated employee must document such review in the client’s record. Breaching client confidentiality is a serious violation of client rights, disciplinary measures will be instituted up to and including termination and/or prosecution. Program staff may not allow other clients, visitors, volunteers or students to review client records. Documentation shall be completed confidentially.

            Handling Agency Documentation

1. Each direct care service paraprofessional / associate professional / qualified professional staff shall document the client’s Service/Treatment Notes on the agency provided forms or, agency computer, as appropriate, daily. Each staff person will receive their own confidential pass code and ID for computer access, as appropriate, and as required according to job duties and responsibilities. Pass codes are not to be shared with other staff, clients, students or volunteers.

2. The Clinical Director/Program Director along with a Qualified Professional shall review each employee’s documentation daily to ensure that all documentation is accounted for. The review shall also include a check for details (i.e. name, shift, date, etc).

3. Staff persons shall be notified of incomplete documentation either by face-to-face conversation or via telephone. The staff person shall be given two (2) working days to complete all data; if the data remains incomplete the Program Director or the staff’s immediate supervisor shall issue a Corrective Action Plan for that employee and the employee will be subject to the Reduction Policy regarding compensation.

4. Once all data is documented, printed, signed, and submitted by staff, the Clinical Director/Program Director/Designated Qualified Professional shall review the data. The data shall then be given to the Qualified Professional in charge of client documentation. A random sampling or all client data will be reviewed and signed by the QP at their discretion.

5. The Qualified Professional shall collect data regarding the records reviewed in order to assist staff in improving their documentation.

6. After completing the review the QP will return the files to the Clinical Director/Program Director/Designated Qualified Professional/Medical Records Personnel who will file the client records, for future review by the Quality Assurance Committee, state officials or auditors.

PERSONS DESIGNATED TO RELEASE CONFIDENTIAL INFORMATION

The Program Director and Qualified Professional are responsible for the release of any confidential information. The Director may delegate, in writing, this responsibility to an employee under their direct supervision.