D.C. Mun. Regs. r. 22-A6323

Current through Register Vol. 71, No. 25, June 21, 2024

Rule 22-A6323 - STORAGE AND RETENTION OF CLIENT RECORDS

6323.1

A provider shall retain client records (either original or accurate reproductions) until all litigation, adverse audit findings, or both, are resolved. If no such conditions exist, a provider shall retain client records for at least ten (10) years after discharge.

6323.2

Records of minors shall be kept for at least ten (10) years after such minor has reached the age of eighteen (18) years.

6323.3

The provider shall establish a Document Retention Schedule with all medical records retained in accordance with Federal and District laws and regulations.

6323.4

If the records of a program are maintained on computer systems, the computer system shall:

(a) Have a backup system to safeguard the records in the event of operator or equipment failure, natural disasters, power outages, and other emergency situations;

(b) Identify the name of the person making each entry into the record;

(c) Be secure from inadvertent or unauthorized access to records in accordance with 42 CFR Part 2 and other Federal and District laws and regulations regarding the confidentiality of client records;

(d) Limit access to providers who are involved in the care of the client and who have permission from the client to access the record; and

(e) Create an electronic trail when data is released.

6323.5

A program shall maintain records that safeguard confidentiality in the following manner:

(a) Records shall be stored with access controlled and limited to authorized staff and authorized agents of the Department;

(b) Written records that are not in use shall be maintained in either a secured room, locked file cabinet, safe, or other similar container;

(c) The program shall implement policies and procedures that govern client access to their own records;

(d) The policies and procedures of a program shall only restrict a client's access to their record or information in the record after an administrative review with documented clinical justification;

(e) Clients shall receive copies of their records as permitted under 42 CFR Part 2;

(f) All staff entries into the record shall be clear, complete, accurate, and recorded in a timely fashion;

(g) All entries shall be dated and authenticated by the recorder with full signature and title;

(h) All non-electronic entries shall be typewritten or legibly written in indelible ink that will not deteriorate from photocopying;

(i) Any documentation error shall be marked through with a single line and initialed and dated by the recorder; and

(j) Limited use of symbols and abbreviations shall be pre-approved by the program and accompanied by an explanatory legend.

6323.6

Any records that are retained off-site must be kept in accordance with this chapter. If an outside vendor is used, the provider must submit the vendor's name, address, and telephone number to the Department.

D.C. Mun. Regs. r. 22-A6323

Final Rulemaking published at 62 DCR 12056 (9/4/2015); amended by Final Rulemaking published at 67 DCR 11585 ( 10/9/2020 ).