13A.11.08.15

.15 Records.

A. The Director shall assure that policies and procedures are developed and maintained to ensure that a confidential record, including electronic and hard copy, is established and maintained for each client admitted to the Center.

B. The record for each client shall include:

(1) Case identification data;

(2) Pertinent history, diagnosis of disability, functional limitation or limitations, and goals;

(3) Reports of assessment and individual program planning;

(4) Reports from referring sources;

(5) Reports of staff conferences;

(6) The individual service plans;

(7) Signed and dated service and progress reports from each Center department providing service;

(8) Release forms;

(9) Reports from outside consultation including laboratory, radiology, medical, or related services;

(10) Designation of the case manager for the client;

(11) Evidence of the client's, and when appropriate, the family's participation in the decision-making process of the client's program;

(12) Discharge information; and

(13) Other information relating to the planning, provision, and management of services to the client.

C. The Center record shall be retained for a minimum of 5 years from the time the client is discharged from the Center.

D. The record shall be maintained in a secure area and may be disclosed to the client, the client's representative, or others only in accordance with the standards set forth in COMAR 13A.11.06.

E. The record may not be removed from the Center unless by court order or with the permission of the Director or Director's designee.

F. Staff members of the Center or the Division who are involved in providing rehabilitation services to a client may maintain a working file relating to the client for their own use in planning, implementing, and managing the services, provided that these files are maintained in a secure place and are not accessible to or revealed to any other person, except in accordance with the standards of COMAR 13A.11.06.