Client Records and Documentation of Services
Sets what the Agency keeps in each client record, how aides document every visit, how entries are made and corrected, where records are kept so the Department can inspect them, how clients see their own records, and how long records are kept before secure destruction. California home care organization law sets no client record content or retention period, so those are the Agency's own standards unless another law is cited.
About this policy
- Policy number
- CA-HC-REC-01
- Version
- 1.0
- Main rule
- Cal. Health & Safety Code §1796.52(c)
- Library
- California home care · 50 policies
- Category
- Records
- Sections
- 19
In short
- Complete a visit record at every visit before you leave the home.
- Write only what you did, saw or were told, with the real time in and time out.
- Never fill in a record ahead of time, sign for someone else or change a record later.
- To fix a paper mistake, draw one line through it, write the correction, and add your initials and the date.
- Keep the home folder out of sight and hand in your visit records every week.
What's inside
19 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (Cal. Health & Safety Code §1796.52(c))
- 5. Contents of the Client Record
- 6. Documenting Each Visit
- 7. Standards for Entries
- 8. Where Records Are Kept
- 9. Client Access to Their Own Record
- 10. Retention and Destruction
- 11. Transfers and Closure
- 12. Responsibilities
- 13. Records and Compliance Monitoring
- 14. Staff Training
- 15. References
- 16. Related Policies and Forms
- 17. Approval
- 18. Revision History
An inspector may ask
- Show me this client's record: the service agreement, the service plan and the visit records for the last month.
- How do aides record what they did at each visit, and who checks those records?
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