Topic Number2.3.12Effective Date

February 1, 2007 (rev)

December 1, 2016

ProcedureIncomplete Records Closure
PurposeTo document standardized protocols and supervisor expectations governing the completion of client records in a timely manner.
Accountability Indicators
  • Client records are consistently completed in a timely manner regardless of staffing vacancies and/or irregularities caused by short-term disability status, long-term disability status, family/medical leave, layoff, termination or voluntary separation of employment, as documented by the WWRC Records Management Services Department.
  • WWRC maintains a complete legal client chart that accurately documents their needs, the care/intervention given, and the outcomes of treatment/intervention, as audited and verified by the WWRC Records Management Services Department.
Policy ReferenceN/A
Detailed Governance ReferenceN/A
Executive Staff ContactSteve Conley, IT Director, WWRC

 

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

 

Governance Procedures

 

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.

 

​Example: This case has been turned over to me, John Doe, as case manager/therapist/counselor for this client as the initial case manager/therapist/counselor is no longer available to continue care/treatment/coordination of services/intervention with this client.

 

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.