A. A
licensee shall ensure that a client record is maintained for each client and:
1. Is protected at all times from loss,
damage, or alteration;
2. Is
confidential;
3. Is legible and
recorded in ink or electronically recorded;
4. Contains entries that are dated and
include the printed name and signature or electronic signature of the
individual making the entry;
5. Is
current and accurate;
6. Contains
original documents and original signature, initials, or authentication;
and
7. Is disposed of in a manner
that protects client confidentiality.
B. A licensee shall ensure that a client
record contains the following, if applicable:
1. The client's name, address, and telephone
number;
2.
Documentation of informed consent to
treatment;
3.
Documentation of the treatment plan and all updates
and revisions to the treatment plan;
4.
2.
Information or records provided by or obtained from another person regarding
the client;
5.
3. Written authorization to release the client's
record or information;
6.
Documentation of requests for client records and of
the resolution of those requests;
7.
Documentation of the release of any information in
the client record;
8.
4. Progress notes;
9.
Documentation of telephone, written, or face-to-face
contact with the client or another individual that relates to the client's
health, safety, welfare, or treatment;
10.
Documentation of behavioral health services provided
to the client;
5.
Informed consent to treatment;
6.
Contemporaneous documentation of:
a. Treatment
plan and all revisions to the treatment plan;
b. Requests for client records and resolution
of the requests;
c. Release of any
information in the client record;
d. Contact with the client or another
individual that relates to the clients health, safety, welfare, or treatment;
and
e. Behavioral health services
provided to the client;
11.
7. Other information
or documentation required by state or federal law.
12.
8. Financial records,
including:
a. Records of financial
arrangements for the cost of providing behavioral health services;
b. Measures that will be taken for nonpayment
of the cost of behavioral health services provided by the licensee.
C. A licensee shall
make client records in the licensee's possession promptly available to another
health professional and the client or the client's legal representative in
accordance with A.R.S. §
12-2293.
D. A licensee shall make client records of a
minor client in the licensee's possession promptly available to the minor
client's parent in accordance with A.R.S. §
25-403.06.
E. A licensee shall retain records in
accordance with A.R.S. §
12-2297.
F. A licensee shall ensure the safety and
confidentiality of any client records the licensee creates, maintains,
transfers, or destroys whether the records are written, taped, computerized, or
stored in any other medium.
G. A
licensee shall ensure that a client's privacy and the confidentiality of
information provided by the client is maintained by subordinates, including
employees, supervisees, clerical assistants, and volunteers.
H. A licensee shall ensure that each progress
note includes the following:
1. The date a
behavioral health service was provided;
2. The time spent providing the behavioral
health service;
3. If counseling
services were provided, whether the counseling was individual, couples,
family, or group; and
4. The dated
signature of the licensee who provided the behavioral health service.
