Ohio Admin. Code 5122-27-02 - Individual client record requirements
(A)
Each provider
shall maintain a complete and adequate individual client record for each
client.
(B)
An individual client record shall mean the account
compiled by health and behavioral health care professionals of information
pertaining to client health, addiction, and mental health; including, but not
limited to, assessment of findings and diagnosis, treatment details, and
progress notes.
(C)
Documentation of consent for treatment, refusal to
consent, or withdrawal of consent, shall be kept in the individual client
record.
Consent by minors shall be in accordance with sections 5122.04 and 3719.012 of the Revised Code.
(D)
A provider shall include documentation regarding:
(1)
Service
fees;
(2)
The individual's, or individual's parent or guardian,
responsibility for payment.
Responsibility for payment includes any portion not covered by insurance or other funding source.
(E)
Documentation to reflect that the client was given a
copy of the following:
(1)
Service or program expectations of clients, if
applicable. Examples include required attendance, or maintaining a sober
environment, and consequences if client does not meet
expectations.
(2)
Summary of the federal laws and regulations that
indicate the confidentiality of client records are protected as required by 42
C.F.R. part B, paragraph 2.22, if applicable.
(F)
Each
authorization for release of information form signed by the
client.
(G)
If provided, documentation verifying the client's
attendance at alcoholism and drug addiction client-education.
(H)
Providers shall
maintain treatment records for at least seven years after a client has been
discharged from a program or services are no longer provided, and prevention
records for at least three years.
Replaces: 5122-27-02
Notes
Promulgated Under: 119.03
Statutory Authority: 5119.36
Rule Amplifies: 5119.36
Prior Effective Dates: 9/4/03, 3/25/04, 1/09/06
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.