Policy Manual


Closing a Case Record Instructions      

Type: Policy                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care employees and contractees

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Supporting References: 

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Policy:  Closing a Case Record Instructions 1. The Case Coordinator (CC) or designee will be responsible for closing a case record for any case to which they have been assigned. · Records will be closed and sent to Bangor within 30 days of client discharge. · The CC/designee will ensure that all documents required in the record are, in fact, in the record, or documentation stating the reason for the form not being present will be entered in its place. · All information must be removed from the case record binder(s). · Any portions of the file that were archived/thinned must either be inserted back into the file, in the corresponding sections, and in the manner determined by the table of contents (e.g., Section 1 – Intake/Discharge includes all client placement information forms in reverse chronological order, all Child Placement Agreements in reverse chronological order, all Placement Level Agreement forms in reverse chronological order, all other forms will follow in this manner) Or, the archived/thinned sections may be kept separate in one envelope and reviewed in the same manner as described herein. · Identify each section by writing the section number on a blank piece of 8.5 x 11 paper and place at the beginning of the section (e.g., Section 1 – Intake/Discharge, Section 2 - Releases/Legal, and so on). · The final Discharge Summary and Aftercare Services Checklist should be placed at the beginning of the record, prior to the Section 1 title page. · Every form entered into the client record must contain the Client ID# - please check to ensure this is so before closing the record and sending it to Bangor. · Once you have all the information placed in the correct order, place it in a white Tyvek Expansion Envelope(s) (PLEASE DO NOT pull off the tape covering to seal this envelope, ONLY TAPE IT closed with scotch tape). On the outside of each envelope, print in permanent marker the following information; A. The client’s legal name (if an adoption client, you must also indicate former name) B. The client’s case number C. Date of discharge in the mm/dd/yy format D. The number of envelopes the file is contained in – (If more than one envelope is required to close the record, including archived/thinned material, number all of the envelopes related to that client. For example; 1 of 3, 2 of 3, 3 of 3, etc.) E. If one of the envelopes above is archived material, include the words “Archived Material” on the outside of the envelope along with the information listed above, or if there is more than one envelope, please enter what is contained in the envelope (e.g., Sections 1 through 8). F. The Unit Code for the program from which the client is closed. 2. Transfer closed record(s) to the Bangor office for a quality assurance review and incorporation into Community Care closed records system. Please follow the Transporting Case Records Procedure when removing and transporting client records. (Locked Bags) 3. All old materials such as file folders, file tabs, and envelopes that had contained record/archived materials must be shredded immediately or reused if they can be de-identified. 4. All closed records must be transported to Bangor where they will receive a final QA check as a part of the CQI plan. All closed records are stored in the Skowhegan Office once the Q/A department has reviewed them. 5. When closed records are transported to Bangor, the records should be given to the individual at the front desk. 6. When a record is closed and delivered to the Bangor office it should be logged in at the front desk and an email message should be sent to the Director of Quality Improvement and/or the Coordinator of Quality Assurance identifying the client name, ID number, and discharge date. 7. Questions regarding this procedure should be directed to the Director of Quality Improvement or designee. 8. If records received in Bangor are not closed properly they will be returned to the area with an explanation regarding what areas need to be addressed. Aroostook area records, as well as Kennebec area records, are exempt from this specific part of the procedure due to distance and timing issues. For these two areas the records will be processed by the Quality Assurance Coordinator with a list of areas within the record that needed to be addressed returned to the supervisor of the area and the manager of foster care. 9. Anytime a case is re-opened, the assigned CC should request the closed file from the closed records system through the office of Quality Improvement, and the information contained therein should be added to the client’s new record or maintained as archived information at the area site.