Sec. 10.21.02.05. Records

A. Clinical records shall contain sufficient information to identify the patient clearly, to support the diagnosis, to justify the treatment plan, and to document the results accurately.

B. A clinical record shall be established for every person admitted to a day treatment program and shall include:

(1) Identifying information, including names, current addresses, and telephone numbers of the patients, relatives, or guardians;

(2) Presenting problem, the results of mental and physical examinations, diagnosis, treatment plan, a record of the implementation of the treatment plan, and the discharge disposition and referrals;

(3) Evidence of appropriate release-of-information procedures and informed consent, if applicable.

C. A system of identification and filing of clinical records shall be maintained to facilitate the prompt location of the patient's clinical record.

D. Provision shall be made for storing records to assure their security and to maintain their confidentiality.

E. The record shall be retained for at least 3 years after the discharge of a patient unless the patient is a minor. In that case, it shall be retained for at least 3 years past the date on which the minor would reach the age of majority. Record retention by State or State-funded programs shall conform to the requirements of the records management division.