Policy Manual

 
  3.MEP.6  

Client Access to Records      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: 

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Executive Director    N/A
Related Document Code Related Document Name Type

Procedure:  .

1.      If a client currently in care asks to see his/her record, the request will be referred to the Case Coordinator. The Case Coordinator, in conjunction with the Team Clinical Supervisor, will then do one of two things within three working days of the client's request:

a.       Enter a note in the record indicating that there is no clear indication that such examination by the client would be harmful.

b.      Enter a note in the record that there are clear reasons that such an examination would be harmful to the client at that particular time. These reasons will be documented and entered into the record. This decision will be made known to the client, the client's guardian, and the of Maine Development Executive Director. If the client persists in his/her desire to review the record, (s)he may do so, under the close supervision of the Team Clinical Supervisor.

2.      If a former client asks to see his/her record, the Operations Manager will determine the Case Coordinator and/or the Team Clinical Supervisor who formerly provided service to that client, and refer the request to him/her(them). The Case Coordinator and/or the Team Clinical Supervisor will then take action as described for current clients above.

3.      If a former client is not known by any current Case Coordinator or Team Clinical Supervisor and a decision cannot be appropriately made regarding the potential harm to the former client reviewing his/her record, arrangements will be made for the former client to be seen and evaluated by a qualified clinician for the express purpose of determining whether the former client should have access to his/her record.

4.      If a client or former client requests a copy of case record material, it will be the responsibility of the Case Coordinator or Team Clinical Supervisor to provide such copies. There will be no charge for this service.

5.      The client or former client will be notified regarding any material in their record that has been obtained from other (non- Development of Maine) sources and will be directed to obtain copies of this material from the other sources.