Minnesota Administrative Rules

9530.6440 CLIENT RECORDS.

Subpart 1.

Client records required.

A license holder must maintain a file of current client records on the premises where the treatment services are provided or coordinated. The content and format of client records must be uniform and entries in each case must be signed and dated by the staff member making the entry. Client records must be protected against loss, tampering, or unauthorized disclosure in compliance with Minnesota Statutes, section 254A.09, Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67, and Code of Federal Regulations, title 45, parts 160 to 164, and, if applicable, Minnesota Statutes, chapter 13.

Subp. 2.

Records retention.

Records of discharged clients must be retained by a license holder for seven years. License holders that cease to provide treatment services must retain client records for seven years from the date of facility closure and must notify the commissioner of the location of the records and the name of a person responsible for maintaining the records.

Subp. 3.

Client records, contents.

Client records must contain the following:

A.

documentation that the client was given information on client rights, responsibilities, grievance procedures, tuberculosis, and HIV, and that the client was provided an orientation to the program abuse prevention plan as required under Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (4);

B.

an initial services plan completed according to part 9530.6420;

C.

a comprehensive assessment completed according to part 9530.6422;

D.

an assessment summary completed according to part 9530.6422, subpart 2;

E.

an individual abuse prevention plan that complies with Minnesota Statutes, sections 245A.65, subdivision 2, and 626.557, subdivision 14, when applicable;

F.

an individual treatment plan, as required under part 9530.6425, subparts 1 and 2;

G.

progress notes, as required in part 9530.6425, subpart 3; and

H.

a summary of termination of services, written according to part 9530.6425, subpart 4.

Subp. 4.

Electronic records.

A license holder who intends to use electronic record keeping or electronic signatures to comply with parts 9530.6405 to 9530.6505 must first obtain written permission from the commissioner. The commissioner must grant permission after the license holder provides documentation demonstrating the license holder's use of a system for ensuring security of electronic records. Use of electronic record keeping or electronic signatures does not alter the license holder's obligations under state or federal law, regulation, or rule.

Statutory Authority:

MS s 241.021; 245A.03; 245A.09; 254A.03; 254B.03; 254B.04

History:

29 SR 129; 32 SR 2268

Published Electronically:

October 15, 2013