Client Service Records: Content, Handling, and Retention
Sets out what every client record contains under 10A NCAC 13J .1402, how entries are dated, signed and corrected, how originals and copies are kept and secured on the licensed premises, the five-working-day return of a record removed for evaluation with a sign-out log, release only with the client's written authorization or as the law permits, and how long records are kept: the Agency keeps every client record at least six years after the most recent discharge, which meets the five years in 13J .1401(f), the NC Medicaid rule and the HIPAA documentation period, and longer for minors and records under audit.
- Policy number
- NC-HC-REC-01
- Version
- 1.0
- Main rule
- 10A NCAC 13J .1401
- Library
- North Carolina home care · 50 policies
- Category
- Records
- Sections
- 18
In short
- Every client has one record. Put the client's full name on every page.
- Write the real date on every entry and sign it. Mark anything written late as "late entry" with today's date.
- Fix a paper error with one line, the word "error", your initials and the date. Never erase, white out or remove pages.
- Keep the home folder out of sight and never leave client papers in your car or take them home.
- Only the office releases records, and only with the client's written permission or as the law allows.
- Records are kept at least six years after discharge. Never throw away a client paper yourself.
What's inside
18 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (10A NCAC 13J .1401)
- 5. What Every Client Record Contains
- 6. Making, Signing and Correcting Entries
- 7. Originals, Copies, and Electronic Records
- 8. Removing a Record from the Premises
- 9. Access to and Release of Client Records
- 10. Retention, Storage, 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
- Show me a closed record. Where are the signed rights form, the referral source, the assessment of the home environment and the discharge summary?
- How do you mark an entry made late or out of sequence?
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