Section 29-2355. RECORDS MANAGEMENT -- STANDARDS FOR STORAGE AND RETENTION OF PATIENT RECORDS

 

2355.1 A substance abuse treatment facility or program shall retain patient records (either original or accurate reproductions) for at least five (5) years or until all litigation, adverse audit findings, or both, are resolved.

 

2355.2 Records of minors shall be kept for at least five (5) years after such minor has reached the age of eighteen (18) years.

 

2355.3 Each facility or program shall place a copy of the “Rights of Patients” statement, signed by the patient, in the patient’s record.

 

2355.4 The patient or legal guardian shall also be given a written statement concerning patient’s rights and responsibilities in the program. The patient or guardian, attesting to his or her shall sign the statement 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 patient’s record.

 

2355.5 If the records of a facility or 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 “Confidentiality of Alcohol and Drug Abuse Patient Records” 42 C.F.R., Part 2, and District laws and regulations regarding the confidentiality of patient records; and

 

(d) Limit access to providers who are involved in the care of the patient and who have permission from the patient to access the record, and create an electronic trail when data is released.

 

2355.6 A substance abuse treatment facility or program shall abide by federal laws and regulations concerning the confidentiality of records in accordance with “Confidentiality of Alcohol and Drug Abuse Patient Records” 42 C.F.R., Part 2, and District laws and regulations regarding the confidentiality of patient records.

 

2355.7 A substance abuse treatment facility or program shall maintain records in a manner that safeguards 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; and

 

(c) The facility or program shall implement policies and procedures that govern patient access to their own records.

 

2355.8 The policies and procedures of a substance abuse treatment facility or program shall not restrict a patient’s access to their record or information in the record.

 

2355.9 The policies and procedures of a substance abuse treatment facility or program shall specify that a staff member must be present whenever a patient accesses his or her records. If the patient disagrees with statements in the record, the patient’s objections shall be written in the record.

 

2355.10 All staff entries into the record shall be clear, complete, accurate and recorded in a timely fashion.

 

2355.11 All entries shall be dated and authenticated by the recorder with full signature and title.

 

2355.12 All entries shall be typewritten or legibly written in indelible ink that will not deteriorate from photocopying.

 

2355.13 Any documentation error shall be marked through with a single line and initialed and dated by the recorder.

 

2355.14 Limited use of symbols and abbreviations shall be pre-approved by the facility or program and accompanied by an explanatory legend.

 

2355.15 For all facility or program services, the record shall document the following for each service episode:

 

(a) Name of service rendered and a synopsis of the service activity;

 

(b) The date and actual beginning and ending time the service was rendered;

 

(c) Legible signature and title of person who rendered the service;

 

(d) Location in which the services were rendered if other than the facility or program site; and

 

(e) The relationship of the services to the rehabilitation treatment plan.

 

2355.16 The service episode note documenting family therapy shall clearly state the relationship of the participant(s) to the patient.

 

2355.17 For each group session, a group log shall document the type of service, date, actual beginning and ending time, attendance and the signature and title of the staff member providing the service.

 

2355.18 A substance abuse treatment facility or program shall have a written policy for conducting periodic record reviews to evaluate completeness, accuracy, and timeliness of entries.

 

 

source

Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7782 (September 22, 2000).