Policy Manual

 
  13.MEP.5  

Disposition of Client Records      

Type: Procedure                 Category: QA/QI                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: COA G11.4.03/04/05

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Management Team  5/97, 9/18  5-1-1997
Related Document Code Related Document Name Type

Procedure:  1. All Community Care client records will be maintained in a locked file cabinet within a locked room at the Community Care Program site serving that client. 2. No client record may be removed from a record room without signing it out. 3. Only authorized staff members may sign out a client record. 4. All Community Care records will be categorized as 1) Open; 2) Inactive, but open; or 3) Inactive and closed. Client record status will be identified in the client database. 5. All inactive and closed records will be reviewed annually for disposition. Those records which have had inactivity for seven years or more will be identified for the purpose of destruction or purging. 6. When a case record is identified as closed and without contact for seven years, the records clerk will compile a list of all case files to be destroyed consisting of client name, case number, birth date and date of destruction. 7. The client data base will be updated to include the information "Record Destroyed" and the date destroyed. 8. The case records will then be destroyed by shredding. 9. Certain material in open cases over 7 years old that is deemed "no longer relevant" in the opinion of the Case Coordinator for the case, the Clinical Supervisor, and the client or guardian may be destroyed. Documentation, signed by the client and/or the guardian should be entered into the record any time such disposition is determined to be appropriate. This documentation should state what information is being destroyed, the reason for destroying the information, and who approved this disposition. 10. Substance abuse case records for a minor will be kept for six years following the client's 18th birthday regardless of the status of the record. 11. Records associated with adoption may not be destroyed regardless of age or period of inactivity.