Policy Manual

 
  3.MEP.9  

Client Record Maintenance      

Type: Procedure                 Category: Service Delivery                 Level: Community Care 

Parties: Community Care Employees and Contractees

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Supporting References: COA Standard RPM 6: Security of Information: RPM 6.01, 6.02

Parent Effective Date Approval Level Revision Dates Last Reviewed
N/A  5-1-1997  Executive Director  10/08  10-1-2008
Related Document Code Related Document Name Type

Procedure:  .

Community Care protects confidential information from unauthorized disclosure or use and unintentional or intentional destruction through the following measures:

  1. Client records will be stored in a locked and secure storage area.
  2. Client records will be clearly marked with client name and case record number.
  3. Electronic record keeping systems will have restricted access through access codes or other automated security systems.
  4. All electronic record keeping systems will have a back-up system maintained off premises and will have appropriate safeguards in place such as firewalls and anti-virus software.
  5. Client records may be accessed only by authorized personnel on a need to know basis. These personnel will include:
    1. Community Care employee responsible for case record
    2. Clinical Supervisor
    3. Program Coordinator
    4. Program Director
    5. Executive Director
    6. Other staff or contractees as appropriate determined by a Clinical Supervisor.
  6. All records taken from the secure storage area must be signed for by using the "Record Sign-Out Sheet". The Record Sign-Out Sheet includes the following information:
    1. Date
    2. Record (client name)
    3. Provider signature & title
    4. Time out/in
    5. Purpose for removal