309-014-0036 - Records

309-014-0036. Records

(1) Service Records. A record shall be maintained for each client who receives direct treatment training and/or care services. The record shall contain client identification, problem assessment, treatment, training and/or care plan, medical information when appropriate; and progress notes.

(2) Retention of Records. Records shall be retained in accordance with OAR 166-005-0000 through 166-040-0010 (State Archivist). Financial records, supporting documents, statistical records, and all other records (except client records) shall be retained for a minimum of three years after the close of the contract period, or until audited. Client records shall be kept for a minimum of seven years.

(3) Confidentiality of Client Records. Client records shall be kept confidential in accordance with ORS 179.505, 45 CFR 205.50 and 42 CFR Part 2, any Division administrative rule pertaining to client records, and the most current edition of the Division Handbook on Confidentiality.

(4) Client Rights. Each agency providing any community mental health service shall have written procedures to assure:

(a) Protection of client privacy and dignity;

(b) Confidentiality of records consistent with state statutes and federal statutes and regulations;

(c) Involvement of the client in planning the service through the provision of information, presented in general terms, which explains the following:

(A) The treatment to be undertaken;

(B) Alternative treatment methods available, if any; and

(C) Risks that may be involved in the training or treatment, if any.

(d) Client's right to refuse service unless otherwise ordered by a court; and

(e) Client is provided with information, presented in general terms, concerning the agency fee policies.

(MHS 23-2016, f. & cert. ef. 12-1-16)

Stat. Auth.: ORS 413.042 & 430.640

Stats. Implemented: ORS 430.610 - 430.640

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