6 Colo. Code Regs. § 1011-1-2.7
Current through Register Vol. 47, No. 11, June 10, 2024
Section 6 CCR 1011-1-2.7 - Client Records2.7.1 A confidential client record shall be maintained for each individual receiving services from the BHE.2.7.2 Each client record shall include, but not be limited to: (A) Demographic and medical information, including, but not limited to, client name, address, telephone number, emergency contact information, physician or health provider information, current diagnosis, and current physician's orders.(B) Screenings, assessments, service plans, documentation of informed consent, releases of information, physician or practitioner orders, documentation of services, treatment progress and medication, the discharge summary, and any endorsement or service-specific requirements, as set by this Chapter.(C) The client's medication administration record, if applicable, kept in accordance with Part 2.9.2 of this Chapter.2.7.3 A BHE shall maintain and provide access to client records in accordance with the requirements of 6 CCR 1011-1, Chapter 2, Part 6, with the following additions or exceptions: (A) Records shall be retained as follows: (1) Records for adults shall be retained for ten (10) years from date of discharge from the BHE.(2) Records for individuals who are less than eighteen (18) years old when admitted to the BHE shall be retained until the individual is twenty-eight (28) years old.(B) The confidentiality of the individual record, including all medical, mental health, substance use, psychological, and demographic information, shall be protected in accordance with all applicable federal and state laws and regulations, including during record use, storage, transportation, and disposal.(1) The confidentiality of the record shall not be construed to limit the access of the Department for purposes of assuring compliance with these rules.(C) The BHE shall establish guidelines for reporting breach or potential loss of individual identity and service information in accordance with state and federal confidentiality statutes and regulations.(D) When a BHE closes a physical location and/or discontinues any endorsement, it shall maintain records of clients served in accordance with the requirements of this Part.(E) A BHE that ceases operation must comply with the provisions of 6 CCR 1011-1, Chapter 2, Part 2.14.4 regarding individual records.