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37.106.1452    CLIENT RECORD MAINTENANCE AND SYSTEM REQUIREMENTS

(1) Each service provider must have a comprehensive client record system maintained in accord with recognized principles of health record management. The service provider must ensure:

(a) a designated individual is responsible for the record system;

(b) a secure storage system which protects active and inactive files from damage;

(c) client record policies and procedures addressing:

(i) who has access to records;

(ii) content of active and inactive client records;

(iii) a systematic method of identifying and filing individual client records so each can be readily retrieved;

(iv) assurance each client record is complete and authenticated by the person providing the observation, evaluation, or service;

(v) retention of client records for a minimum of six years three months after the discharge or transfer of the client; and

(vi) procedures for destruction of client records.

(d) procedures for maintaining electronic client records (if applicable).

(2) In case of an agency closure, the provider closing its treatment agency must arrange for continued management of all client records. The closing provider must notify the department in writing of the mailing and street address where records will be stored and specify the person managing the records. The closing provider may:

(a) continue to manage records and give assurance they will respond to authorized requests for copies of client records within a reasonable period of time;

(b) transfer records of clients who have given written consent to another certified provider;

(c) enter into a service organization agreement with a state approved chemical dependency provider to store and manage records, when the outgoing provider will no longer be a business and provide a copy of the agreement to the department.

History: 50-5-103, 53-24-208, MCA; IMP, 50-5-101, 50-5-103, 53-24-306, 76-2-411, MCA; NEW, 2010 MAR p. 2975, Eff. 12/24/10.

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