Section 130. Case records

A. Agency staff shall maintain a case record for each resident in which all significant decisions and events are recorded. The records shall include, at a minimum, but are not limited to, the following information:

1. Initial intake information form;

2. Case information from referral source;

3. Case and social history;

4. Emergency contact information;

5. Medical record, when available;

6. Individual plan or program, group and family counseling;

7. Signed release of information forms;

8. Evaluation and progress reports;

9. Current employment data;

10. Documentation that program rules and policies have been reviewed with the resident;

11. Grievance and disciplinary record;

12. Subsequent referrals to other agencies by the program; and

13. Termination summary.

B. Agency staff shall make entries into the case records and date and initial each entry.

C. Case records shall be marked "confidential" and maintained in locked file cabinets or rooms to minimize the possibility of theft, loss, destruction or unauthorized use.

D. Supervisory staff or a designee shall review case records monthly to ensure that the case is current and accurate.

E. The confidentiality of case records shall be maintained in accordance with federal and state laws. Written procedures shall govern access to case records and designate personnel responsible for release of resident information.

F. Written procedure shall govern the retention and destruction of case records in accordance with state law.

G. Agency staff shall provide a "Release of Information Consent Form" which at a minimum complies with applicable federal and state laws and includes:

1. Person, agency or organization requesting information;

2. Person, agency or organization releasing information;

3. Specific information to be disclosed;

4. Purpose or need for the information;

5. Expiration date;

6. Date consent form is signed;

7. Signature of the resident; and

8. Signature of individual witnessing resident's signature.

Historical Notes

Derived from VR230-30-004:1 § 4.3, eff. July 1, 1993; amended, Volume 16, Issue 24, eff. September 17, 2000; Volume 25, Issue 03, eff. November 15, 2008.

Statutory Authority

§ 53.1-5 of the Code of Virginia.