Section 280. Client record system

A. The organization shall maintain an organized client record system according to accepted standards of practice. Written policies and procedures shall specify retention, reproduction, access, storage, content, and completion of the record.

B. The client record information shall be safeguarded against loss or unauthorized use.

C. Client records shall be confidential. Only authorized personnel shall have access as specified by state and federal law.

D. Provisions shall be made for the safe storage of the original record and for accurate and legible reproductions of the original.

E. Policies shall specify arrangements for retention and protection of records if the organization discontinues operation and shall provide for notification to the OLC and the client of the location of the records.

F. An accurate and complete client record shall be maintained for each client receiving services and shall include, but shall not be limited to:

1. Client identifying information;

2. Identification of the primary care physician;

3. Admitting information, including a client history;

4. Information on the composition of the client's household, including individuals to be instructed in assisting the client;

5. An initial assessment of client needs to develop a plan of care or services;

6. A plan of care or service that includes the type and frequency of each service to be delivered either by organization personnel or contract services;

7. Documentation of client rights review; and

8. A discharge or termination of service summary.

In addition, client records for skilled and pharmaceutical services shall include:

9. Documentation and results of all medical tests ordered by the physician or other health care professional and performed by the organization's staff;

10. A medical plan of care including appropriate assessment and pain management;

11. Medication sheets that include the name, dosage, frequency of administration, possible side effects, route of administration, date started, and date changed or discontinued for each medication administered; and

12. Copies of all summary reports sent to the primary care physician.

G. Signed and dated notes on the care or services provided by each individual delivering service shall be written on the day the service is delivered and incorporated in the client record within seven working days.

H. Entries in the client record shall be current, legible, dated and authenticated by the person making the entry. Errors shall be corrected by striking through and initialing.

I. Originals or reproductions of individual client records shall be maintained in their entirety for a minimum of five years following discharge or date of last contact unless otherwise specified by state or federal requirements. Records of minors shall be kept for at least five years after the minor reaches 18 years of age.

Historical Notes

Derived from Volume 22, Issue 03, eff. January 1, 2006; amended, Virginia Register Volume 24, Issue 11, eff. March 5, 2008.

Statutory Authority

§§ 32.1-12 and 32.1-162.12 of the Code of Virginia.