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Piedmont Community Services. Clinical Records Policy Training Friday, June 6, 2014. Agenda. Review Policy Review Forms Demonstration of Online Forms. Kippy Cassell Shirley Jamison Susan Coe Rich Patterson Kim Dillow. Brenda Kahle Patti Williamson Frances Scoggin Carol Chittum

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Piedmont community services

Piedmont Community Services

Clinical Records Policy Training

Friday, June 6, 2014


  • Review Policy

  • Review Forms

  • Demonstration of Online Forms

Committee members

Kippy Cassell

Shirley Jamison

Susan Coe

Rich Patterson

Kim Dillow

Brenda Kahle

Patti Williamson

Frances Scoggin

Carol Chittum

Terri Crews

Committee Members

Purpose of the policy
Purpose of the Policy

  • Required by DMHMRSAS

  • Protect consumers confidentiality

  • Meet requirements of HIPAA

  • Outline procedures relating to clinical records

  • Standardize clinical forms throughout PCS

H i p a a

  • Health Insurance Portability & Accountability

    • Privacy Guidelines – 4/16/03

    • Transaction Standards – 10/16/03

    • Security Standards

    • Standard Provider Identification

    • Electronic Signature Standards

Location security access
Location, Security & Access

  • All records stored under double locks.

  • Only transported between PCS facilities.

  • No persons shall have access to records except in the provision of services.

  • Must be kept in a confidential location at all times.

  • Records should be returned to file room at the end of each business day.

  • Access to all clinical records will be recorded.

Confidentiality disclosure
Confidentiality & Disclosure

  • The strictest confidentiality standards will be imposed.

  • All HIPAA regulations will be adhered to.

  • A record of all disclosures will be maintained.

  • All requests for information shall be processed through the medical records department.

Direct consumer access
Direct Consumer Access

  • Consumers ordinarily are granted access to their records.

  • Access may be limited if provider feels disclosure would be harmful to consumer.

  • Consumers have the right to challenge, correct or explain any information contained in their record.

Conditional disclosure
Conditional Disclosure

  • Emergency Disclosure

    • May be made to any person necessary when an emergency exists.

  • Courts

    • All properly executed subpoenas must be responded to .

    • SA records may only be released with an accompanying court order.

    • Unless motion to quash is filed.

  • Third Party Payers

    • May disclose certain information for payment by third-party payers.

Conditional disclosure cont
Conditional Disclosure (cont.)

  • Accrediting and Licensing Agencies

  • Child Abuse and Neglect Reporting

  • Adult Abuse Reporting

  • Medical Examiner

Record re disclosure
Record Re-disclosure

  • Any Information received and used in the consumers treatment must be kept in the permanent record.

  • Authorization shall be obtained from the consumer before releasing any information from outside CSB sources.

Faxing information
Faxing Information

  • Faxing information shall only occur when the original paper record or mail delivery cannot meet the immediate emergency care.

Structure content
Structure & Content

  • Structure and content of charts have changed.

  • Clip 3 & 4 reserved for medical services.

  • Committee working on redesigning remaining clips for clinical services.

  • Only new and reopened charts will have new structure.

Retention destruction
Retention & Destruction

  • PCS will follow the Virginia Public Records Act, for the retention and destruction of records.

  • Must keep records 10 years after discharge.

  • Must be kept permanently:

    • Client’s legal name

    • Social Security Number

    • Date of client’s birth

    • Date of Admission & Discharge

    • Name & address of legal guardian, if any

Opening closing review process

Opening, Closing & Review Process

Opening a case
Opening a Case

  • All intake paperwork should be completed on the first visit.

  • Intake packets are provided for intake.

  • Forms should be routed to data entry for processing.

  • At least one program enrollment must accompany intake paperwork.

  • Once entered, chart will be created and filed in the appropriate file room.

Program release
Program Release

  • When releasing a consumer from an individual program:

    • Remove the enrollment form from the chart and complete the reverse side

    • Complete a Transfer/Discharge summary (form 112)

    • Submit to data entry for processing

Case review process
Case Review Process

  • A case review process shall exist for each unit of PCS.

  • Must address issues such as:

    • Completeness

    • Accuracy

    • Timeliness of entries

  • At a minimum, must be completed every 90 days on all open records.

Agency form instructions
Agency Form Instructions

  • Only “BLACK” Ink may be used in charts.

  • May use online version of forms.

  • Only approved forms may be used.

  • Clinical Records Committee must approve all changes to agency forms.

Intake questionnaire form 101
Intake Questionnaire (form 101)

  • No changes made.

Diagnosis addendum form 102
Diagnosis Addendum (form 102)

  • Added lines under diagnosis for description.

  • Added description for Axis 3

  • Added box to check for:

    • Update – Cannot use Data Change Form

    • No Change

Program enrollment form 103
Program Enrollment (form 103)

  • No changes made

Assessment social history form 104
Assessment / Social History (form 104)

  • Added “Onset” to presenting problem section.

  • Added more lines to service provider list

  • Added lines to describe Mental Status symptoms.

Assessment social history update form 104b
Assessment / Social History Update(form 104b)

  • New Form:

    • Use to update a previous social history.

  • Indicate reason for update

  • Indicate areas of previous social hx. being updated

  • Describe in narrative form, the information being updated.

  • Sign form, and indicate if a change in ITP is required.

Standard progress note form 105
Standard Progress Note (form 105)

  • No changes made.

Smi sed at risk checklist form 107
SMI/SED/At Risk Checklist (form 107)

  • No changes made.

Individual treatment plan form 108
Individual Treatment Plan (form 108)

  • Changed “Weaknesses” to “Clinical Issues/Functional Limitations”

Quarterly status update form 109
Quarterly/Status Update (form 109)

  • Completely revised form.

  • Use one form per update.

  • Do not remove previous updates from chart.

  • Indicate service update is for.

  • Document the following:

    • 1. Evaluation of consumers progress toward goal.

    • 2. Review and revision of service plan

    • 3. The need for continued service.

Consent for release of info form 110
Consent for Release of Info. (form 110)

  • Added Expiration Date of the Consent.

Data change form form 111
Data Change Form (form 111)

  • No form changes

  • Effective 11/1/2002 – All provider changes will result in the old enrollment being closed and a new enrollment created with the transfer date for the appropriate provider.

  • No Diagnosis Changes on Data Change Form. Must use Diagnosis Addendum.

Transfer discharge summary form 112
Transfer/Discharge Summary (form 112)

  • Completely redesigned form.

  • Mostly in checklist format.

  • Completed at each program release.

  • Indicate services provided.

  • Indicate progress made toward each goal.

  • Indicate discharge diagnosis (all axis’)

  • Indicate medications.

  • Indicate reason for transfer/discharge.

  • Indicate who referred to.

  • Indicate recommendation, follow-up, comments.

Your rights form 113
Your Rights (form 113)

  • No changes made.

Acknowledgement of rights form 114
Acknowledgement of Rights (form 114)

  • Added multiple signature lines.

Medication informed consent form 115
Medication Informed Consent (form 115)

  • No changes made.

Initial needs assessment form 116
Initial Needs Assessment (form 116)

  • Used by crisis / intake workers.

  • No changes made.

Tb referral form form 117
TB Referral Form (form 117)

  • No changes made.

In house drug testing log form 119
In-house Drug Testing Log (form 119)

  • Used to record all in-house urine/drug testing.

  • No changes made.

Clinical treatment note form 120
Clinical Treatment Note (form 120)

  • “Modalities of Treatment” changed to “Treatment Interventions”.

Service group log
Service & Group Log

  • Added service codes to back of form.

Priority population checklist form 123
Priority Population Checklist (form 123)

  • No changes made.

Physician referral ack form form 124
Physician Referral Ack. Form (form 124)

  • Added “Use Psychiatric Evaluation from prior hospitalization” to form.

  • Copy authorization on back of form when applicable.

Provider choice form form 125
Provider Choice Form (form 125)

  • Added Consumer name & Acct/SSN.

  • Expanded form to encompass all service areas.

  • Added more facilities to checklist.

  • Added option for consumer to check if he/she chooses not to receive medical care and/or treatment.

  • Added staff signature line.

Release of information invoice form 126
Release of Information Invoice (form 126)

  • Changed fee back to a per/page fee.

Case management progress note form 127
Case Management Progress Note (form 127)

  • New Form

  • Used by case management to document progress notes.

Vital signs flow sheet form 128
Vital Signs Flow Sheet (form 128)

  • New form

  • Used by nursing staff (primarily in Y&P) to document consumers vital signs.


  • Implement Records Policy Immediately

  • After 11/1/02, all forms submitted must be dated 6/1/2002.

  • 11/1/02 – 1/1/03, Grace period for forms. After 1/1/03 old forms will be returned.

Tasks ahead for clinical records committee
Tasks ahead for Clinical Records Committee

  • Update Physician Referral Form

  • Develop flow/content of chart. (sub-committee)

  • New volumes.

  • Filing process.

  • New Treatment Plan.

  • Data Change Flow/Process.

  • Paper reduction.

  • Active Status of Cases.

  • Treatment Plans vs. Insurance Plans.

  • Cases open to doctors.

  • Consistency in all counties.