Search and Seizure Policy

YOUTH CONSULTATION SERVICE

7.5 Policy and Procedure for Record Retention

Applicability: Group Homes, Residential Treatment Centers, Psychiatric Community Residences, Treatment Homes, Partial Care Programs, and Shelters.

Policy: YCS shall ensure that all client Medical and Clinical records are retained in accordance with all applicable state and federal regulations*.

Procedures: A. Clinical1 and Medical2 Records

1. All clinical and medical records shall be retained for: a. At least 10 years from the date of last entry into the record, b. or until the former client is 25 years old, c. WHICHEVER IS LONGER d. This means that all records will be kept until each former client is at least 25 years old. e. By way of example, a client who leaves YCS at 10 years old will have his or her record maintained until the former client turns 25 years old, and a client who leaves YCS at 21 years old will have his or her record maintained until that former client turns 31 years old. 2. Prior to destroying a record, the client’s discharge summary shall be maintained. a. The facility will retain the discharge summary for a period of 20 years. b. The discharge record shall include admission and discharge dates, name and address of the client, final diagnosis, summary of treatment or therapy rendered, discharge conditions and instructions including medications, etc.

B. Storage of Records

1. All Medical and Clinical records shall be stored in a locked, dry location, on or offsite as determined by the Regional Vice President or designee. 2. Each program shall have access to its records for the entire duration of storage. 3. Records shall be destroyed after the expiration period of retention limitations. 4. Prior to destroying the record, the program will confirm, with the YCS Research Department, the date of last discharge from YCS. If necessary, the program will then note this date and continue to store the record until this time has run out. 5. The mode of storage will be determined by the YCS President/CEO based on compliance with state, federal and JCAHO requirements.

*Regulations: Board of Medical Examiners- 13:35-6.5(b); Social worker Board of Regulations- 13:44G 12.1(e); NJAC 10:75-1.5; 10:37-6.77, 10:128, 10:124; NJ Statute 26:8-5 1-Clinical Records focus on a client’s mental and emotional health . This record is completed by the clinical department including psychologists, social workers and therapists. 2-Medical Records focus on a client’s physical well being. It is completed by the medical department including nurses, physicians and APNs.

Date Effective: March 5, 2007

Revised 3/5/07 P:\Research\PIA\CRM\7.5 p.1