Cal. Code Regs. Tit. 22, § 76925 - Client Record Service
(a)
The client record service shall provide for the collection, organization and
confidentiality of client information.
(b) Unit client records shall be kept current
and complete in detail consistent with good medical and professional practice
based on the service provided to each client.
(c) All required records, either originals or
accurate reproductions, shall be maintained in a legible form and promptly
available upon the request of all authorized users and any authorized employee
or agent of the Department.
(d) All
current clinical information related to the client's individual service plan
shall be centralized in the individual's unit client record. It shall be
immediately available to the direct care staff. Inactive records or thinned
portions of the active unit client record shall be securely stored in the
facility or an off-site area approved by the Department.
(e) Client record storage areas shall be
clean and protect the information from loss, destruction or defacement by fire,
flood, humidity, insects or unauthorized access.
(f) Information contained in the unit client
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.
(g) Unit client records
shall be retained for seven years from the last date of service, except for
records of minors, which shall be kept at least three years after the client
has reached the age of eighteen and, in any case, not less than seven
years.
(h) The unit client record
is the property of the facility and shall be maintained for the benefit of the
client, the interdisciplinary professional staff/team and the
facility.
(i) The Department shall
be informed within three business days prior to any cessation of a facility's
operation of the arrangements made for the safe preservation of the unit client
records.
(j) The Department shall
be informed within three business days in writing, whenever unit client records
are defaced or destroyed before the termination of the required retention
period.
(k) 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 unit client records and these records will be
available to the former licensee, the new licensee and other legally authorized
persons; or
(2) That other
arrangements have been made by the current licensee for the safe preservation
and the location of the unit client records, and that they are available to
both the new and former licensees and other legally authorized persons;
or
(3) The reasons for the
unavailability of the records.
(l) The facility shall maintain a perpetual
alphabetical index of all clients which includes at least:
(1) Identifying data;
(2) Dates of admission and
discharge;
(3) Current location of
all records.
Notes
Note: Authority cited: Sections 208.4 and 1267.7, Health and Safety Code. Reference: Section 1276, Health and Safety Code.
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