1. (1)(a) The licensee shall develop and maintain a record keeping system that includes a separate record for each client with documentation of the client's health care, active treatment services, social information and protection of the client's rights.

   1. (b) The licensee shall protect confidential information contained in the client's records.
   2. (c) The licensee shall develop and implement policies and procedures governing the release of any client information, including consent necessary from the client or client's legal guardian.
   3. (d) The licensee shall ensure entries into client records shall be legible, dated and signed by the individual making the entry.
   4. (e) The licensee shall provide a legend to explain any symbol or abbreviation used in a client's record.
   5. (f) The licensee shall ensure each identified residential living unit has available on-site pertinent information of each client's record.
   6. (g) The licensee shall ensure client records are complete and systematically organized according to facility policy to facilitate retrieval and compilation of information.
2. (2) A Registered Health Information Administrator or a Registered Health Information Technician shall oversee the client record department through employment or consultation. If retained by consultation, onsite visits shall be at least semi-annually and documented through written reports to the administrator.

3. (3) The licensee shall:

   1. (a) safeguard client records from loss, defacement, tampering, fires and floods;
   2. (b) protect client records against access by unauthorized individuals;
   3. (c) retain client records for at least seven years after the last date of client care; and

   4. (d) retain records of minors as follows:

      1. (i) at least two years after the minor reaches age 18 or the age of majority; and
      2. (ii) a minimum of seven years.

4. (4)(a) The licensee shall retain client records within the facility upon change of ownership;

   1. (b) If a licensee ceases operation, the licensee shall arrange for appropriate safe storage and prompt retrieval of client records, client indexes and discharges for the period specified.
   2. (c) The facility may arrange storage of client records with another facility or may return client records to the attending physician who is still in the community.

KEY: health care facilities

Date of Last Change: December 19, 2023

Notice of Continuation: February 9, 2022

Authorizing, and Implemented or Interpreted Law: 26B-2-202