LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 401.01 Clinical Records Maintenance
 
  PROCEDURES
  1. Storage
     
    1. All paper clinical records shall be in locked files.
       
    2. Clinical documentation and clinical correspondence shall not be kept or stored (paper or any electronic media other than an Electronic Health Record [EHR]) outside of the record storage secure site.
       
    3. Off-site storage of clinical records must be arranged through the Custodian of Records or their designee.
       
  2. Release
     
    1. Directly operated staff must comply with the provisions of all Los Angeles County Department of Mental Health (DMH/Department) Health Insurance Portability and Accountability Act of 1996 (HIPAA)-related policies (500 Series) as well as the Clinical Records Guidelines manual which establishes specific procedures for the proper organization and maintenance of client records and the disclosure of Protected Health Information (PHI) based on federal, State, and local laws and regulations including HIPAA, WIC § 5328, and accepted standards of professional practice.
       
    2. Contracted providers are not subject to the provisions of the Clinical Records Guidelines, but are subject to their own relevant policies and all applicable provisions of federal, State, and local laws and regulations including HIPAA, WIC § 5328, and accepted standards of professional practice.
       
  3. Retention
     
    1. All clinical records and PHI shall be retained for a period that is at least equivalent to the later of any of the following:
       
      1. 10 years following the conclusion of services;
         
      2. For minors, until such time as the minor reaches 25 years of age;
         
      3. 10 years after completion of all County, State and/or federal audits; or
         
      4. 10 years after the conclusion of any audit appeal and/or when audit findings are fully resolved.
         
    2. All documents created and scanned into the EHR after the implementation of the EHR shall be destroyed upon confirming the document(s) were successfully scanned into the EHR.
       
      1. Documents originally created as part of a paper clinical record are subject to the retention period in Section C.1 and must be returned to the paper clinical record after scanning into the EHR.