Cal. Code Regs. Tit. 22, § 76557 - Client Records

(a) Records shall be permanent, either typewritten or legibly written in ink and shall be kept on all clients admitted or accepted for care. All records of discharged clients shall be completed and filed within 30 days after the discharge date and the records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until 1 year after the minor has reached the age of 18, but in no case less than 7 years. If a facility operates an X-ray unit, all exposed X-ray film shall be retained for seven years. All required records, either originals or faithful and accurate reproductions shall be maintained in a legible form and available upon the request of the attending physician; the facility or any authorized officer, agent or employee of either the physician or the facility; any authorized employee or agent of the Department or any other person authorized by law to make a request.

(b) Information contained in a client's records, including information contained in an automated data bank, shall be considered confidential and shall be protected from unauthorized access or use and released only to authorized persons in accordance with federal, state and local laws.

(c) Written consent of the client, parent of a minor, guardian or authorized representative shall be required for the release of information to persons not otherwise authorized to receive it.

(d) If a facility ceases operation, the Department shall be informed within 24 hours of the arrangements made for the safe preservation of the client's records.

(e) The Department shall be informed within 48 hours, in writing, whenever client records are defaced or destroyed before termination of the required retention period.

(f) If the ownership of the facility changes, both the licensee and the applicant for the new license shall, prior to the change of ownership, provide the Department with written documentation stating:

(1) That the new licensee will have custody of the client's records and these records will be available to the former licensee, the new licensee and other authorized persons; or

(2) That other arrangements have been made by the current licensee for the safe preservation and the location of the client's records, and that they are available to both the new and former licensees and other authorized persons; or

(3) The reasons for the unavailability of the records.

(g) Client records shall be current and kept in detail consistent with good medical and professional practice based on the service provided to each client. Such records shall be filed and maintained in accordance with these requirements and shall be available for review by the Department. All entries in the client record shall be authenticated with the name, title classification, date and time.

(h) There shall be a master alphabetical index of all clients admitted to and currently clients of the facility.

(i) The facility shall maintain an organized central record service for the collection and dissemination of information regarding clients for the use of authorized personnel only.

(j) Client records shall be stored so as to be protected against loss, destruction or unauthorized use.

(k) Client records shall be filed in an easily accessible manner in the facility or in client record storage. Storage of records shall provide for prompt retrieval when needed for continuity of care. Client record storage off the facility premises shall be approved by the Department.

(1) The client record is the property of the facility and is maintained for the benefit of the client interdisciplinary team and facility and shall not be removed from the facility, except for storage purposes after client discharge.

Notes

Cal. Code Regs. Tit. 22, § 76557

Note: Authority cited: Section 208(a), Health and Safety Code. Reference: Section 1276, Health and Safety Code.