| I. PURPOSE
| | This policy informs Los Angeles County Department of Mental Health (DMH/Department) about clinical records maintenance including storage, release, and retention.
Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
| | II. DEFINITIONS
| Clinical Record: An official record containing all clinical information and services related to a client. - Paper Clinical Record: An official record containing all clinical information and services related to a client in paper format and stored in a secured file cabinet.
- Electronic Health Record (EHR): An official record containing all clinical information and services related to a client in an electronic format and stored in an electronic database.
Custodian of Records: The manager responsible for the safeguard, maintenance, and authorized disclosures of clinical records and Non-Open PHI Files (as applicable) and direct oversight of the Department’s Health Information Management (HIM) operations.
Keeper of Records: The individual at each provider site designated by the program manager to be responsible for ensuring the procedures set forth in this policy are adhered to.
Protected Health Information (PHI): Individually identifiable health information held or transmitted in any form or medium, whether electronic, paper, or oral, relating to the past, present or future physical or mental health condition of an individual; the provision of health care to an individual; or the past, present or future payment for the provision of health care to an individual. The information identifies the individual or can be used to identify the individual. (45 CFR 160.103)
| | III. POLICY
| All providers must maintain a clinical record. - For directly operated providers, the official clinical record is a DMH-approved EHR.
- Contracted providers shall have an EHR that meets all requirements of the Organizational Provider's Manual or Network Provider’s Manual, this policy, and DMH Policy 401.03.
All clinical records of directly operated providers are the property of DMH.
The Custodian of Records is responsible for ensuring all directly operated providers meet the procedures set forth in this policy. - If any provider terminates its operation, its management shall work with the Custodian of Records or their designee to ensure proper and orderly transfer, storage, or destruction of all clinical records held by the provider.
The program manager shall designate a Keeper of Records at each directly operated provider site. - The Keeper of Records is responsible for ensuring the procedures set forth in this policy are adhered to at the provider site.
All paper clinical records shall be safeguarded against loss, defacement, tampering, or use by unauthorized persons in accordance with Section A of this policy's Procedures.
Clinical records and other PHI shall be released only as specified in provisions of federal, State, and local laws and regulations including: - Health Insurance Portability and Accountability Act (HIPAA) of 1996
- California WIC § 5328
- Accepted standards of professional practice
- Applicable contractual requirements
- Section B of this policy's Procedures
Clinical records and other PHI must be retained as described in Section C of this policy's Procedures.
| | IV. PROCEDURES
| | | | V. AUTHORITIES
| California Business and Professions Code Division 2 Chapter 6.6 California Code of Regulations Title 22 Sections 75343 and 77143
California Welfare and Institutions Code Section 5328
Code of Federal Regulations Title 45 Parts 160 and 164
Code of Federal Regulations Title 42 Part 438.3(u)
Health Insurance Portability and Accountability Act (HIPAA) of 1996
California Welfare and Institutions Code Section 14124.1
| VI. ATTACHMENTS
| Medi-Cal Specialty Mental Health Services Fee-for-Service (FFS) Network Provider Manual (FFS Network Provider Manual)
Short-Doyle/Medi-Cal Organizational Provider’s Manual for Specialty Mental Health Services (Organizational Provider’s Manual) | |
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