Section 75343 - Unit Patient Treatment Records(a) Records shall be permanent, either typewritten or legibly written in ink, and shall be kept on all patients accepted for treatment. All treatment records of discharged patients shall be completed and filed within 30 days after termination of each episode of treatment and such records shall be kept for a minimum of 7 years, except for minors whose records shall be kept at least until one (1) year after the minor has reached the age of 18, but in no case less than seven (7) years. All required records, either originals or accurate reproductions thereof, shall be maintained in such form as to be legible and readily available upon the request of the attending psychologist, the clinic or any authorized officer, agency or employee of either, or any other person authorized by law to make such request.(b) Information contained in the treatment records shall be confidential and shall be disclosed only to authorized persons in accordance with federal, state or local laws.(c) If a psychology clinic ceases operation, arrangements shall be made for the safe preservation of the patients' treatment records. The Department shall be informed by the clinic of these arrangements prior to the 48 hours before cessation of operations.(d) The Department shall be informed within 48 hours, in writing, by the licensee whenever patient treatment records are defaced or destroyed before termination of the required retention period.(e) If the ownership of the clinic changes, both the licensee and the applicant for the new license shall, prior to the change of ownership, provide the Department with written documentation stating: (1) That the licensee shall have custody of the patients' treatment records and these records shall be available to the former licensee, the new licensee and other authorized persons; or(2) That other arrangements have been made by the current licensee for the safe preservation and the location of the patients' treatment records and they are available to both the new and former licensees and other authorized persons.(f) Patients' treatment records shall be current and kept in detail consistent with good professional practice and shall describe the services provided to each patient. All entries shall be dated and be authenticated with the name and professional title of the person making the entry.(g) Patients' treatment records shall be stored so as to be protected against loss, destruction or unauthorized use.(h) Patient treatment records shall be filed in an easily accessible manner in the clinic. Storage of records shall provide for prompt retrieval when needed for continuity of care. Prior approval of the Department is required for storage of inactive treatment records away from the facility premises.(i) The patient treatment record shall be the property of the facility and shall be maintained for the benefit of the patient, treatment team and clinic and shall not be removed from the psychology clinic, except for storage purposes after termination of services or as required by law.Cal. Code Regs. Tit. 22, § 75343
1. New section filed 3-13-87; effective thirtieth day thereafter (Register 87, No. 12). Note: Authority cited: Sections 208(a) and 1225, Health and Safety Code. Reference: Sections 1204.1 and 1226, Health and Safety Code.
1. New section filed 3-13-87; effective thirtieth day thereafter (Register 87, No. 12).