February 1, 2007 (rev)
December 1, 2016
Every Day in Every Way We…..
Put Clients First
Take Care of Customers
Work in Teams
Are Organized, Utilized, and Valuable
Preserve Leadership Ethics, Accountability, Center Values, and Public Trust
WWRC employees responsible for client records and reports are expected to follow the guidance in this governance procedure to ensure that client records and reports are completed in a timely, quality manner.
All records that are left incomplete by an employee for any reason shall be turned over to the immediate supervisor for review.
The supervisor is expected to reassign the case to another employee to continue the care/intervention with the client; OR determine if the (case) notes or any other documentation the employee has on the client (including therapy reports, training reports or any other outcome oriented report describing events of treatment or intervention while the client is enrolled at WWRC) is adequate to construct a summary report if the client is discharged from that line of service or program.
If the supervisor determines that the case notes and/or reports submitted to the record documenting progress, intervention or care to the client is adequate, then the supervisor or designee is expected to construct a report based on the available information. The supervisor or designee is expected to state in the report who they are and why they are doing the report.
If the supervisor determines that the (case) notes are inadequate or are not available, and no other documentation is available (such as therapy, training, life skills, etc.), the Records Management Services Supervisor will review the client chart and send an incomplete closure notice to the respective Division Director. If the Division Director deems there is not adequate documentation to construct a summary (via case notes and or other reports submitted to the chart) the Records Management Services Supervisor will grant closure of the chart.
When a chart is closed as incomplete, Records Management Services staff will file a notice in the client chart stating why the record was closed as incomplete.