PARTNERSHIP FOR CHILDREN OF ESSEX

POLICY MANUAL

Subject: Client/Case Record Maintenance

Number: A-05

Effective Date: February 9, 2004

Purpose:

To maintain the Client Record and all relevant forms in standard and uniform order and to ensure that all appropriate and necessary documentation is up to date in every case file.

Policy:

PCE views the Client Record as a legal document. Case files will be organized in a standard, uniform order and all appropriate and necessary documentation will be maintained and up to date in every case file. The Client Record includes both the “hard copy” file kept at PCE and the electronic record that is stored as part of the Contracted Systems Administrator’s Managed Information System.

Procedure:

A.Components of the Client Record:

  1. The case record will be established within 3 days of client referral from the CSA.
  2. The case record will include the following information or forms:
  • Family’s consent for release of information
  • Appropriately signed releases of information as needed
  • Signed Privacy Policy Verification form
  • Signed Client Rights and Responsibilities Verification form
  • All information received from the CSA or Selection Team during the referral process
  • Child and family contact and demographic information including identification of significant persons to the child and family
  • Interim Crisis Plan
  • Strength and Needs Assessment
  • All ISP’s
  • Progress Notes
  • Any other relevant information such as:
  • Psychiatric evaluations
  • Legal information
  • School information
  • DYFS information
  • Etc.
  1. Chart Entries:

1.The assigned Care Manager will document all contacts and attempts to contact clients/families.

2.The Client Record is a legal document and information entered into the record is to be clear, factual, and state information pertinent to client services and progress.

  1. Client Records are to be maintained in a locked file room and must not leave the PCE premises.
  1. Client Records are not to be left unattended and/or out in the open. They are confidential and only those involved in services may have access.
  1. The Client Record serves to reflect quality of care. The Quality Manger and Administrative staff of PCE will review and/or monitor records as part of the overall quality initiative of the organization.
  1. All standards of the Confidentiality Policy are to be followed in maintaining case records.
  1. All responsible staff will ensure that case records are consistently up to date and well maintained.

Any PCE employee who does not exhibit proper care of PCE client case records may be subject to disciplinary action.

Policy revised and approved on September 26, 2004

______

Jeffrey J. Guenzel, Executive Director

A-05