CENTRAL OHIO MENTAL HEALTH CENTER
Subject:
Client Records – ODADAS
Section:
11.05.05.02.00
Effective Date: 01/15/2009
Approved by: ______________________________
Larry Westbrook, Board President
PURPOSE:
To establish the Center’s minimum client record requirement for alcohol and
drug addiction certification/licensure according to the Ohio Department of
Alcohol and Drug Addiction Services (OAC 3793: 2-1-06)
DEFINITIONS:
A. "Admission" means a program's decision to offer alcohol and drug addiction services to
a person and includes opening an individual client record (ICR).
B. "Admission Date" means the day, month and year when a client is officially,
administratively enrolled by the program for an episode of care.
APPLICABILITY: The procedures of this rule are applicable to the Center’s alcohol and drug
addiction programs.
POLICY:
I.
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The Center has written policies and/or procedures for maintaining a uniform client
records system that includes, but is not limited to, the following:
A.
Confidentiality of client records (as evidenced by the Center Confidentiality
(#03.03.01.00) and Use and Disclosure of Protected Health Information
(#08.01.03.00) policies.
1)
Program staff shall not convey to a person outside of the program that a
client attends or receives services from the program or disclose any
information identifying a client as an alcohol or other drug services client
unless the client consents in writing for the release of information, the
disclosure is allowed by a court order, or the disclosure is made to a
qualified personnel for a medical emergency, research, audit or program
evaluation purposes.
2)
Federal laws and regulations do not protect any threat to commit a crime,
any information about a crime committed by a client either at the program
or against any person who works for the program.
3)
Federal laws and regulations do not protect any information about
suspected child abuse or neglect from being reported under state law to
appropriate state or local authorities
B.
Access to client records by individuals other than clients or staff is described in
Center policy and procedures for Use and Disclosure of Protected Health
Information (#08.01.03.00 and #08.01.03.01) and Minimum Necessary Use and
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C.
D.
E.
F.
Disclosure (#08.01.01.00).
Release of client information is described in Center policy on Use and Disclosure
of Protected Health Information (#08.01.03.00)
Components of client records and timelines, when applicable, for completing
each component in AOD Clinical Records Procedure (#11.05.05.02.01) and
Integrated Client Record System (#05.05.02.00).
Storage of client records requires client records be maintained in accordance
with 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Client Records is
described in AOD Clinical Records Procedure (#11.05.05.02.01).
Destruction of client records to include the requirement that records be
maintained for at least seven years after clients have been discharged from the
program as evidenced by the AOD Clinical Records Procedure
(#11.05.05.02.01). Client records shall be destroyed to maintain client
confidentiality as required by state and federal law according to the Center’s
Record Retention and Disposal Policy (# 05.05.01.00).
II.
The Center shall maintain documentation for services provided. All documentation,
except case management services and non-treatment services (for example, client
returning to program after attending alcoholics anonymous meeting, etc.) completed by
Registered Candidates, Chemical Dependency Counselor Assistants, and student
interns shall be countersigned by an individual qualified to be an alcohol and drug
treatment services supervisor pursuant to Rule 3793:2-1-08 of the Administrative Code.
III.
Components of client records shall include, but not be limited to, the following as
evidenced by the Integrated Client Records System Policy and Procedures
(#05.05.02.00 and 05.05.02.01)
A.
identification of client by name and/or client identification number (as evidenced
by Financial Intake/Review forms),
B.
assessment (as evidenced by Adult Diagnostic Assessment and Health History
Questionnaire forms),
C.
consent for alcohol and other drug treatment services (as evidenced by Consent
for Treatment form),
D.
client fee agreement (as evidenced by the Financial Responsibility and Service
Agreement form),
E.
documentation to reflect that the client was given a copy of the following:
1)
program rules or expectations of clients (as evidenced by the
Acknowledgement Client Rights and Program Services ),
2)
client rights and grievances procedures (as evidenced by the AOD Client
Rights and Program Service brochure), and
3)
written summary of the federal laws and regulations that indicate
confidentiality of client records are protected as required by 42 CFR Part
B, Paragraph 2.22 (as evidenced by AOD Client Rights and Program
Service Brochure),
F.
diagnosis (as evidenced by the Adult Diagnostic Assessment and Individual
Service Plan forms),
G.
treatment plans (as evidenced by the Individual Service Plan form),
H.
progress notes (as evidenced by the Individual Service Note forms),
I.
disclosure of client information forms (as evidenced by the Authorization for Use
and Disclosure of Protected Health Information form), when applicable, and
J.
termination summary/discharge plan (as evidenced by the Closing Summary
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form).
IV.
The Center shall give written notification to clients, which is in compliance with the
federal laws and regulations on the confidentiality of alcohol and drug abuse client
records (as evidenced by AOD Client Rights and Program Service Brochure).
V.
Disclosure of client information forms shall include the following information as required
by 42 CFR, Part 2 (as evidenced by the Authorization to Use and Disclosure of
Protected Health Information form):
A.
Name of the program making the disclosure,
B.
Name or title of the individual or the name of the organization to which the
disclosure is to be made,
C.
Name of the client,
D.
Purpose of the disclosure,
E.
Type and amount of information to be disclosed,
F.
Original signature of the client or person authorized to give consent,
G.
Date client or other authorized person signed the form,
H.
Statement that the consent is subject to revocation at any time except to the
extent the program or person who is to make the disclosure has already acted in
reliance on it, and
I.
The date, event, or condition upon which the consent will expire, unless revoked
before that specified time.
VI.
Each disclosure, made with the client’s written consent, must be consistent with 42 CFR,
Part 2, by including the following written statement (as evidenced by the Authorization
for Use and Disclosure of Protected Health Information form):
“This information has been disclosed to you from records protected by Federal
confidentiality rules. The Federal rules prohibit you from making any further disclosure
of this information unless further disclosure is expressly permitted by the written consent
of the person to whom it pertains or as otherwise permitted by 42 CFR, part 2. A
general authorization for the release of medical or other information is not sufficient for
this purpose. The Federal rules restrict any use of information to criminally investigate
or prosecute any alcohol or drug abuse client.”
VII.
A diagnosis shall be made by a clinician who can independently diagnose substancerelated disorders as authorized by the Ohio Revised Code, and shall be recorded in
each client’s record upon completion of the assessment. Supporting documentation in
the client record shall include:
A.
Identification of the client,
B.
Diagnosis and DSM code number,
C.
Signs and symptoms justifying the diagnosis,
D.
Date the diagnosis was made, and
E.
Original signature and credentials of the clinician making the diagnosis.
F.
The Center may accept a diagnosis made within 90 days of the admission date
of a client to the AoD program by a clinician who can diagnose substancerelated disorders as authorized by the Ohio Revised Code.
VIII.
An individualized treatment plan (see Individual Service Plan form) shall be written for
each client within seven (7) days of completion of the assessment or at the time of the
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first face-to-face contact following assessment. Individualized treatment plans shall be
based on assessment and included, at a minimum, the following:
A.
Client Identification (name and/or identification number),
B.
Level of care to which client is admitted,
C.
Problem(s) to be addressed,
D.
Measurable goals that address client’s needs,
E.
Measurable treatment objectives with time frame for achievement of each
objective,
F.
Frequency, duration and types of treatment services as described in Rule
3793:2-1-08 of the Ohio Administrative Code,
G.
Original signature of the client, and
H.
Date, original signature, and credentials of the person who completed the plan
and is qualified to provide alcohol and drug addiction services in accordance with
Rule 3793:2-1-08 of the Ohio Administrative Code.
IX.
The Center has written policies and procedures for clients that specify criteria and time
frames for reviewing and updating an individualized treatment plan which take into
account the client’s changing clinical needs and response to treatment. (See Center
Policy # 04.04.02.00 Individual Service Plan) For individuals receiving alcohol and drug
addiction services, the ISP will be reviewed every six months or whenever there is a
change in level of care and updated as appropriate utilizing the Individual Service PlanReview and Update form.
X.
Progress notes (as evidenced by the Individual Service Note (ISN) form) shall be written
to reflect the implementation and evaluation of treatment plans for clients admitted to
programs. Progress notes are required to include sufficient content to justify the client’s
continuing need for services. Each service listed in Rule 3793:2-1-08 of the Ohio
Administrative Code delivered to the client, with the exception of urinalysis, shall be
documented in the client’s record with a progress note.
A.
Progress notes shall indicate the progress the client is making towards achieving
the goals and objectives that are identified in the individualized treatment plan.
B.
Progress notes shall indicate the outcomes of treatment interventions which are
stated in the client’s individualized treatment plans.
C.
Progress notes shall include, at a minimum, the following:
1)
Client identification (name and/or identification number),
2)
Date of service contact or service delivery,
3)
Length of time of service contact or service delivery (calculated by the
number of hours, minutes, and/or start and ending time of service
delivery),
4)
Type of service (i.e. case management, individual counseling, group
counseling, crisis intervention, etc.),
5)
Summary of what occurred during the service contact or service delivery,
and
6)
Date, original signature and credentials (registration, certification and/or
license) of the staff member providing the service.
7)
Timeline for completion of all progress notes is one and one half days,
post date of service, and attached to SAL.
D.
Results of urinalysis testing shall be placed in the client’s file per 3793: 2-108(R)(1)(g), which states results of urinalysis/lab analysis testing shall be
reviewed by the program staff and a copy of the results placed in the client’s file.
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Positive results shall be shared with the client.
XI.
The following modalities and/or activities, if provided, shall be documented in each
client’s record: occupational therapy, recreation therapy, activity therapies, parenting
skills training, alcoholism and drug addiction client education, expressive therapies (art,
drama, poetry, music, movement) and nutritional education.
A.
If provided, a Progress Note is not required for parenting skills training,
alcoholism and drug addiction client-education, urinalysis, and nutrition
education; however, documentation verifying the client’s attendance is
necessary.
B.
If provided, a progress note is required for occupational therapy, recreation
therapy, activity therapy, expressive therapy, and nutrition counseling.
XII.
A Termination Summary (as evidenced by the Closing Summary form) shall be prepared
within thirty calendar days after treatment has been terminated. Termination summaries
shall include, at a minimum, the following:
A.
Client identification (client name and/or identification number),
B.
Date of admission,
C.
Date of discharge,
D.
Diagnosis,
E.
The degree of severity at admission and at discharge for the following
dimensions based on the ODADAS protocols for levels of care (adult and youth)
for publicly-funded clients. For non-publicly-funded clients, the degree of
severity at admission and discharge shall be based on the ODADAS protocols
for levels of care or other objective placement criteria:
1)
Intoxication and withdrawal,
2)
Biomedical conditions and complications,
3)
Emotional/behavioral/cognitive conditions and complications;
4)
Treatment acceptance/resistance;
5)
Relapse potential,
6)
Recovery environment, and
7)
Family or caregiver functioning (for youth).
F.
Level of care and service(s) provided during the course of treatment,
G.
Client’s response to treatment,
H.
Recommendations and/or referrals for additional alcohol and drug addiction
treatment or other services, and
I.
Date, original signature, and credentials of a person qualified to provide
counseling services in accordance with rule 3793:2-1-08 of the Ohio
Administrative Code.
XIII.
The Center will develop appropriate policies and procedure to ensure the security and
confidentiality of client records should the Center elect to use electronic client records.
XIV. If The Center discontinues operations or is taken over or acquired by another entity, it
shall comply with 42 CFR, Part 2, Subsection 2.19 which governs the disposition of
records by discontinued programs.
Revision:
Reviewed:
Approved:
2/12/2016
01/15/2009; 05/26/2005
01/15/2009
01/15/2009
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