Behavioral Health Standard 2.G – Records of the Persons Served


The organization implements policies and procedures regarding information to be transmitted to other individuals or agencies that include:

  1. The identification of information that can legally be shared without an authorization for release of information
  2. Forms to authorize release of information that:
    1. Comply with applicable laws
    2. Identify, at a minimum:
      1. The name of the person about whom information is to be released
      2. The content to be released
      3. To whom the information is to be released
      4. The purpose for which the information is to be released
      5. The date on which the release is signed
      6. The date, event, or condition upon which the authorization expires
      7. Information as to how and when the authorization can be revoked
      8. The signature of the person who is legally authorized to sign the release
  3. A description of how it tracks information released
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The individual record communicates information in a manner that is:

  1. Organized
  2. Clear
  3. Complete
  4. Current
  5. Legible
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All documents generated by the organization that require signatures include original or electronic signatures.

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The individual record includes:

  1. The date of admission
  2. Information about the individual’s personal representative, conservator, guardian, or representative payee, if any of these have been appointed, including the name, address, and telephone number
  3. Information about the person to contact in the event of an emergency, including the name, address, and telephone number
  4. The name of the person currently coordinating the services of the person served
  5. The location of any other records
  6. Information about the individual’s primary care physician, including the name, address, and telephone number, when applicable
  7. Financial agreement with the person served
  8. Healthcare reimbursement information, if applicable
  9. The person’s:
    1. Health history
    2. Current medications
    3. Preadmission screening, when conducted
    4. Documentation of orientation
    5. Assessments
    6. Person-centered plan, including reviews
    7. Transition plan
  10. Progress notes
  11. A discharge summary
  12. Correspondence pertinent to the person served
  13. Authorization for release of information
  14. Documentation of internal or external referrals
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Entries to the records of the persons served follow the organization’s policy that specifies timeframes for entries.

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If duplicate information or reports from the main record of a person served exist, or if working files are maintained, such materials:

  1. Are not substituted for the main record
  2. Are considered secondary documents, with the main record of the person served receiving first priority
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