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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-A. MENTAL HEALTH |
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Chapter 22-A63. CERTIFICATION STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT AND RECOVERY PROVIDERS |
Section 22-A6321. STORAGE AND RETENTION OF CLIENT RECORDS
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6321 STORAGE AND RETENTION OF CLIENT RECORDS
6321.1 A program shall retain client records (either original or accurate reproductions) until all litigation, adverse audit findings, or both, are resolved. If no such conditions exist, a program shall retain client records for at least six (6) years after discharge.
6321.2 Records of minors shall be kept for at least six (6) years after such minor has reached the age of eighteen (18) years.
6321.3 The provider shall establish a Document Retention Schedule with all medical records retained in accordance with District and Federal law.
6321.4 The client or legal guardian shall be given a written statement concerning client's rights and responsibilities (“Client’s Rights Statement”) in the program. The client or guardian shall sign the statement attesting to his or her understanding of these rights and responsibilities as explained by the staff person who shall witness the client's signature. This document shall be placed in the client's record.
6321.5 If the records of a program are maintained on computer systems, the database shall:
(a) Have a backup system to safeguard the records in the event of operator or equipment failure, natural disasters, power outages, and other emergency situations;
(b) Identify the name of the person making each entry into the record;
(c) Be secure from inadvertent or unauthorized access to records in accordance with 42 C.F.R. part 2 "Confidentiality of Alcohol and Drug Abuse Patient Records," and District laws and regulations regarding the confidentiality of client records;
(d) Limit access to providers who are involved in the care of the client and who have permission from the client to access the record; and
(e) Create an electronic trail when data is released.
6321.6 A program shall maintain records that safeguard confidentiality in the following manner:
(a) Records shall be stored with access controlled and limited to authorized staff and authorized agents of the Department;
(b) Written records that are not in use shall be maintained in either a secured room, locked file cabinet, safe, or other similar container;
(c) The program shall implement policies and procedures that govern client access to their own records;
(d) The policies and procedures of a program shall only restrict a client's access to their record or information in the record after an administrative review with clinical justification has been made and documented;
(e) The policies and procedures of a program shall specify that a staff member must be present whenever a client accesses his or her records. If the client disagrees with statements in the record, the client's objections shall be written in the record;
(f) All staff entries into the record shall be clear, complete, accurate, and recorded in a timely fashion;
(g) All entries shall be dated and authenticated by the recorder with full signature and title;
(h) All non-electronic entries shall be typewritten or legibly written in indelible ink that will not deteriorate from photocopying;
(i) Any documentation error shall be marked through with a single line and initialed and dated by the recorder; and
(j) Limited use of symbols and abbreviations shall be pre-approved by the program and accompanied by an explanatory legend.
6321.7 Any records that are retained off-site must be kept in accordance with this chapter. If an outside vendor is used, the provider must submit the vendor’s name, address, and telephone number to the Department.