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Client Records, Confidentiality, and Retention

Sets out what goes in every client file, who supervises and has custody of client records, to whom and for what purposes a record may be released, how records are kept secure in the office and in the home, and how long they are kept: at least five years from the date of last service.

Preview: full text with a package
About this policy
Policy number
GA-HC-RM-01
Version
1.0
Main rule
Ga. Comp. R. & Regs. 111-8-65-.09(4)(a)
Library
Georgia home care · 49 policies
Category
Records
Sections
18

In short

  • Every client has one complete file: agreement, plan, daily records, supervisory visits, reports and contacts.
  • Never give any client information to anyone yourself. Send every request, including from family, to the office.
  • Write entries at the time, in ink or in the app. Correct mistakes with one line, the date and your initials.
  • Keep the home folder out of sight of visitors and keep office files locked.
  • Client files are kept at least five years after the last service. Report a lost or misplaced record the same day.

What's inside

18 sections. The full text comes with the One-time Policy Pack.

Full text with a package
  • Terms of Reference
  • 1. Purpose
  • 2. Scope
  • 3. Definitions
  • 4. Policy Statement (Ga. Comp. R. & Regs. 111-8-65-.09(4)(a))
  • 5. Contents of the Client File
  • 6. Making Entries
  • 7. Release of Client Records
  • 8. Client Access to the Record
  • 9. Security of Records
  • 10. Retention and Destruction
  • 11. Responsibilities
  • 12. Records and Compliance Monitoring
  • 13. Staff Training
  • 14. References
  • 15. Related Policies and Forms
  • 16. Approval
  • 17. Revision History

An inspector may ask

  • Who supervises the maintenance of client records and who has custody of them? Where is that written?
  • Show me the file of a client admitted last month: the service agreement, the service plan and the record of tasks performed.

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