Minnesota Administrative Rules

7200.4750 RECORD KEEPING.

Subpart 1.

Record-keeping requirements.

Providers shall maintain accurate and legible records of their services for each client. Records shall minimally contain:

A.

client personal data;

B.

an accurate chronological listing of all client visits, fees charged to the client or a third-party payer, and payments received;

C.

documentation of services, including, where applicable:

(1)

assessment methods, data, and reports;

(2)

an initial treatment plan and any subsequent revisions;

(3)

the name of the individual providing the services;

(4)

case notes for each date of service, including any interventions;

(5)

consultations with collateral sources;

(6)

diagnoses or problem descriptions;

(7)

documentation that informed consent for services was given, including written informed consent documents, where applicable;

(8)

documentation of supervision or consultation received; and

(9)

the name of the individual who is clinically responsible for the services provided;

D.

copies of all correspondence relating to the client; and

E.

copies of all client authorizations for release of information and any other documents pertaining to the client.

Subp. 2.

Duplicate records.

The provider need not maintain client records that duplicate those maintained by the agency, clinic, or other facility at which services are provided.

Subp. 3.

Records retention.

The provider shall retain a client's records for a minimum of eight years after the date of the provider's last professional service to the client, except as otherwise provided by law. If the client is a minor, the records retention period shall not commence until the client reaches the age of 18, except as otherwise provided by law.

Statutory Authority:

MS s 148.905; 148.98

History:

37 SR 1085

Published Electronically:

January 31, 2013