Record Keeping of Client Files

Goal - why is this important to us?

Dawn Farm maintains a written record on each client and is committed to ensuring that these records include all pertinent and necessary information and that the confidentiality of this information be safeguarded. To this end, the Clinical Director has been designated as the person responsible for overseeing the development of procedures regarding client records and for the implementation of these procedures.

Ingredients - what do I need to get started?

Client files

Timeframe - about how long will this take?

N/A

Contacts - who do I need to let know?

N/A

Steps - what do I do?

• “Paperwork at Dawn Farm” contains an exact description (including time frames and location in file) of all written documents contained in case files.
• All entries in case files must be signed (including credentials) and dated.
• Open case files will be stored in the facility that can best ensure their safeguarding and ease of access to staff.
• Case file material is NEVER to be left out in the main offices after working hours. This includes desk tops, desk drawers and staff mail boxes. Any loose material with client names, including rosters, that is placed in a staff mailbox should be facing inward to protect confidentiality.
• Case files will be stored either in a locked cabinet or in a locked room, depending on the facility’s needs and practicality.
• In order to avoid any case files being misplaced, all cabinets and file holders will be clearly labeled.
• Dawn Farm will only release information contained in the case file when we are in possession of a valid release of information. These releases must conform to federal and state laws and include the name of the client, the content to be released, the form in which the information is to be released, to whom and for what purpose the information is to be released, the date on which the release will expire, a valid signature of the client and the date on which the release was signed. When information is released, the staff member must record in the case file what specific portions of the record were released, when and to whom. This notation must be signed and dated.
• The only other situations under which case file information will be released is under a circuit court order or in the case of a life threatening emergency.
• Dawn Farm client case files will be held for a period of not less than seven (7) years following a client’s discharge from treatment.
• The President and Clinical Director must approve the destruction of old files by signing a log of all records to be destroyed. These records will be disposed of either by shredding or burning. Prior to destruction, demographic and treatment information will be gleaned for long term follow up and the development of broad statistical analysis.
  • In the event a record is requested during the destruction process the destruction process will be halted until the record is located and retrieved. It will be destroyed when the reason for the request is met.

In the event of Dawn Farm's closure, the President will contact the Substance Abuse Coordinating Agency for assistance in client, financial and personnel file destruction.

Follow-up - what loose ends do I need to wrap up?

N/A

CARF Standard 1.E.3