POLICY:



REVISIONS TO POLICY STATEMENT: YES NO OTHER REVISIONS: YES NO

APPLICATION:

All Northpointe Behavioral Healthcare Systems service sites.

POLICY:

It is the policy of Northpointe Behavioral Healthcare Systems that all service recipient records be retained for a specified period of time as mandated by State and Federal laws. Records are disposed of in accordance with these same laws. The records are stored in an approved area in alphabetical order per year. Child records will be filed in a bright yellow folder and checked annually for retention. The date of destruction will be highlighted on the front of each chart

If, at any time, Northpointe Behavioral Healthcare Systems should cease to exist, all recipient records will be retained at the Michigan Department of Community Health in Lansing, Michigan.

PURPOSE:

To develop a system to retain and dispose of service recipient records per State/Federal guidelines and to ensure access to service recipient medical records.

PROCEDURES:

Michigan Service Recipients/Wisconsin Service Recipients

In accordance with the Michigan Department of Community Health and Wisconsin Administrative Code HFS 92.12(a), all treatment records are retained by NBHS according to the info below.

▪ Adult Case Records – Identifying and Summary Data. This information will document the basic identification for an individual and includes the final face sheet, final discharge summary, psychiatric evaluations, psychiatric medication reviews, and diagnosis. The records will be retained until the last date of service plus 20 years.

• Adult Case Records – Medical Data. Clinical/medical information (consents, releases, treatment plan, financial forms, reports, plans and strategies, assessments, testing, contact sheets, health and history reviews, psychological evaluations, medication order sheets, scripts, labs, correspondence, transfers) will be retained until the last date of service plus 10 years.

• Children Case Records - Medical Data. Clinical/medical information (consents, releases, treatment plan, financial forms, reports, plans and strategies, assessments, testing, contact sheets, health and history reviews, psychological evaluations, medication order sheets, scripts, labs, correspondence, transfers) will be retained until the individual is 6 years past the age of majority (18) and last date of service plus 10 years. For ease of calculating the date of destruction, all child records will be kept until age 28.

• Closed charts reopened within the retention period will be moved to the current year and retention begins again per MDCH General Schedule.

• Any record undergoing federal or state audit shall be maintained until completion of the audit.

• Records relating to legal actions shall be maintained until completion of legal action.

• Once a recipient’s file exceeds the required retention dates, the treatment record is shredded and disposed

of.

Destruction of Records:

Once a recipient’s file exceeds the required retention limit and the record is destroyed, a Certificate of Destruction (COD) is created and filed via the year the chart is closed and remains on file indefinitely.

A Certificate of Destruction may be required for two separate time frames. E.g. destruction of records occurs at 10 years for adult medical information and 20 years for adult psychiatric info. The COD is filled out noting which documents are destroyed at 10 years and filed via the year of case closure. Psychiatric (facesheet & d/c) are reviewed after 20 years, at which time the COD should be pulled from the closure year and updated with final destruction date. It will then be re-filed via initial closure year.

Since the time frames listed above vary, medical records staff will move the identifying information that has a longer retention to the front of the chart, making it easier to remove the info for destruction and retain the necessary info without sorting thru each chart.

Halting the Destruction of a Record(s):

In the event that a legal process is initiated against the organization, records involved shall be secured and locked in the designated medical records area by the Medical Records Specialist.

REFERENCE:

Information obtained from Michigan Department of Community Health and Wisconsin Administrative Code.

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