Topic Number2.3.6Effective Date

September 1, 2013 (rev)

December 1, 2016 (rev)

ProcedureClient Records
Purpose
  • To clarify and distinguish roles and responsibilities of WWRC's Records Management Services Department and Department/Program areas.
  • To document case record standards and expectations. 
  • To document protocols for  the safeguarding of client records.
Accountability Indicators
  • WWRC client records meet (or exceed) established standards for completeness, quality, timeliness, and safeguards as documented through the Records Management Services Department, external accreditation and regulatory audits, and sponsor satisfaction processes. 
  • WWRC employees accountable for client records by position function understand and appropriately apply case record standards and expectations, as observed, reported, and documented.
  • Supervisors of employees accountable for client records by position function hold employees accountable and take corrective actions, as necessary, to address noted deficiencies. 
  • Clients served report inclusion and participation in the development of program goals and service plans and in ongoing Rehabilitation Team meetings between admissions and discharge.
  • There is evidence that client records are safeguarded to protect client confidentiality and privacy, as observed, reported, and documented through formal audits.
Policy Reference
Detailed Governance ReferenceN/A
Executive Staff ContactSteve Conley, IT Director, WWRC

  

Every Day in Every Way We….. 

Put Our Clients First  
 
Take Care of Customers 
 

Work in Teams

Value our Staff

Are Organized, Utilized, and Valuable

Preserve Leadership Ethics, Accountability, Center Values, and Public Trust

 

Governance Procedures
 
WWRC employees are expected to understand and appropriately apply Center standards for maintenance and management of client records, as contained in policy and this governance procedure. WWRC supervisors are expected to monitor compliance and take corrective actions, as needed to address areas of noted deficiencies.  Any vocational programs, grants, or support services working with clients are also subject to these policies and standards.

 

Roles and Responsibilities

Records Management Services

  • Assign the Records Management Services (RMS) Manager as the designated organization Records Officer, accountable for control and management of all client records and charts.  As Records Officer, the RMS Manager is responsible for developing, implementing, managing, and updating the series for and following the established plan for maintenance, disposition of, protection of and disaster recovery of records.   The RMS Manager provides consultation and training to program areas related to records access, release and the safeguarding of client information to comply with applicable federal, state, and Agency policies. 
  • Assign medical form numbers and submit to the Electronic Forms Cabinet, through established processes.
  • Routinely provide Program Supervisors and Division Directors a summary report of delinquent information and timely completion of records based on established standards.
  • Maintain a written plan for the retention and disposal of records, in compliance with DARS and state archive policies and procedures. 

 

Department/Program Areas

  • Designate a Unit Coordinator to establish and maintain a records management procedure for all series assigned to that department.   The Unit Coordinator is expected to contact the Records Officer to:
  • Schedule reviews
  • Initiate additional series; and,
  • Recommend and obtain permission for the destruction of specific records.
  • Document and maintain case records in compliance with established standards. 
  • Take corrective actions, as appropriate, to address areas of noted deficiencies.
  • Participate in regularly scheduled trainings and in-service events related to records access, release, and the safeguarding of client information. 
     

Case Record Standards

For each person admitted to WWRC, a single client record is prepared and maintained to communicate the appropriate client information clearly, concisely, completely and promptly.  

 

The following standards apply to all client records:

  1. Reports are expected to be objective. Information that is subjective is expected to be noted as such.
     
  2. Individual client records must be maintained on a current basis, and be durable, and legible. WWRC staff are expected to:
     
    • record significant changes in clinical status within 48 hours of the event.
    • complete individualized progress reports and specific Service Exit Summaries within 14 calendar days of discharge or service completion.
    • send comprehensive Durable Medical Equipment (DME) Reports to DME and comply with the 7-day report standard.
    • complete client management Discharge Reports within 21 calendar days after discharge from WWRC.

       
  3. Complete client records are expected to include: 
    • The original document, except correspondence, when a copy should be filed.
    • Participant ID number, individual's name, social security number and date of birth. When data is not obtainable, enter the reason in the record.
    • The name and address of all necessary liaisons/contacts, including the person's representative, conservator, guardian and/or representative payee, if one has been appointed for the person served.
    • Pertinent histories, diagnosis of disability, disability code, rehabilitation program goals, prognosis, financial arrangements and expected length of stay.
    • Name of assigned Rehabilitation Counselor.  For individuals in a medical rehab program on Rothrock Hall, the physician manages all treatment decisions.
    • Service/progress notes.
    • Referral source reports
    • Evidence of referrals for services.
    • Reports from consultations and laboratory, radiology, orthotic, prosthetic, vocational and counseling services, etc.
    • Reasons why any referral could not be completed.
    • Evidence of the individual's participation in the decision-making process of his or her own program. This can occur during initial evaluation and planning in the selection of specific service methods, during the service process in dealing with feedback, and in decisions regarding treatment effectiveness, outcomes and future plans.
    • Reports of intake and progress conferences.
    • A comprehensive individualized program plan.  

NOTE:  When the individual is simultaneously involved in more than one service, there should be an overall plan and each service  unit shall have a detailed plan providing for items 1 through 8.

1. Rehabilitation problem or the individual's presenting need.
2. Individual's goals.
3. Treatment services to be provided.
4. Specific service goals.
5. Time intervals at which treatment or service outcomes will be reviewed.
6. Anticipated time frame(s) for the accomplishment of the individual's specified goals.
7. Measures to be used to assess the effects of treatment or services.
8. Person(s) responsible for implementation of the plan.

 

    • Progress reports from each service.
    • Evaluation reports from each service.
    • A discharge report from each service area.
    • Follow-up reports.
    • A signature (full name and title) of person qualified to render the service and date
    • When information and/or photographs have been released or used, there shall be a signed and dated authorization from the person served, or the parent or guardian as appropriate, to release the information or use of the photographs. 

 

Safeguarding Client Records

Client Records are the property of the Virginia Department for Aging and Rehabilitative Services (DARS).   Records are expected to remain on WWRC premises unless in accordance with a judicial order, statute, or special authorization from the DARS Commissioner, WWRC Director, or in compliance with the WWRC Retention and Disposal Plan.  WWRC employees are expected to use proper safeguards to protect records from loss, defacement, or use by unauthorized persons.  

 

The Records Management Services Department has lead accountability for controlled access to client charts and records.  This Department is required to be attended at all times during normal business hours or locked, if otherwise unattended.   

 

WWRC's Student Health, Admissions Department, and Accounts Receivable Services employees have delegated authority for security of records in their respective areas, and are expected to demonstrate proper safeguards to protect client records.  These areas are required to have written area-specific procedures that govern daily client record operations.

 

WWRC employees requesting access to client records and charts through the WWRC Records Management Services Department must identify themselves at entry.  Anyone not on the access list to the Records Management Services Department is required to have approval from the Records Management Services Manager.  WWRC clients are required to make requests through their assigned Rehabilitation Counselor.

 

Unofficial client records that originate in a department and are not part of the official client chart must be kept under lock and key and kept confidential.   These types of files are considered "working files" and, per HIPAA regulations, must be destroyed no later than thirty (30) days post discharge. 

 

The following practices are required for WWRC employee access and review of a client chart/record:

  • Most client charts are electronic; however, for those that are not -- WWRC employees who remove a physical chart from the Records Management Services Department for review purposes are expected to sign the check-out notebook, noting their full name, the client's name, and current date.   Records Management Services staff is expected to put an "out" guide in the record's place until the chart is returned and to place a check mark by the employee's name when the chart is returned.  All charts must be returned on the same day of check-out by 4:45 PM, unless prior approved by the Records Management Services Manager.
  • Client records and charts are expected to remain on campus.  WWRC employees who have checked out an original client chart or record may not take it off Center premises unless directed by a Judicial Order, the DARS Commissioner for an official business reason, or in accordance with WWRC's Retention and Disposal Plan.  A certified copy of the record may be released by the WWRC Medical Records Services Department only after necessary consent or authorization has been obtained.
  • Responsibilities of WWRC employees who check out client charts and records include (but are not limited to):
    • Assure confidentiality of contents and safeguard work area(s) while in possession.  Client charts/records may not be left unattended or where accessible by unauthorized individuals. 
    • Documents within client charts may not be marked in any way except by the originator of the document.
    • Parts of client charts and records may not be removed to be copies for personal use or convenience. 

 

Safeguard practices to protect confidentiality and privacy of WWRC client information and records include, but are not limited to the following strategies:

  • Refrain from discussion of specific client cases with each other in public areas such as hallways, elevators, waiting areas, lounges, buses or cafeterias.
  • When leaving an area, secure client information and records in open view and log-off of computers, requiring a password to access.  Safeguard passwords and do not share with anyone.

 

Limit access to client information to position functions and responsibilities, as defined by the Employee Work Profile, or as directed through a client's specific written authorization and as directed by policy.