I.  PURPOSE
 

To establish a uniform policy and associated procedures in the Los Angeles County Department of Mental Health (DMH) programs for retaining information on an individual prior to opening a clinical record.

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
 

Custodian of Records: The manager responsible for the safeguarding, maintenance, and authorized disclosures of clinical records and Non-Open PHI Files (as applicable) and oversight of the Department’s Health Information Management (HIM) operations.

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)

Non-Open Protected Health Information (PHI) Record: A record containing all PHI related to an individual for whom there is no Clinical Record.
 

III.  POLICY
 

IV.  PROCEDURES
 

V.  AUTHORITIES