Format and Content of Case Records Sample Clauses

Format and Content of Case Records. The contents of the case files shall include clear and specific information pertinent to the service recipient’s situation and the services provided. Brevity is key in documenting the nature of services provided. All entries shall contain only the information necessary to document the nature of the service(s) provided. Case records shall be free of any reference to service recipient feelings, emotional/psychological assessments, personal commentary or observations, etc. and shall not contain direct quotes from the service recipient. Records developed/maintained concerning all adult and minor domestic violence service recipients shall be maintained in separate files. Programs must have a written policy regarding the right of service recipients to access their own case records and the procedure for informing the service recipient of the right and the process for obtaining access to their records. Policy statements shall reflect the following: • The procedures to be followed in order for service recipients to access their own case files/records; • Who, other than the primary service recipient, is permitted access and under what circumstances; • Who is responsible for handling all requests from service recipients for access to case records; • The time frame for responding to service recipient requests for information. • The manner in which the material is to be shared (e.g. oral discussion, reading the record or duplicating the information; and • A procedure for service recipients to correct, amend or challenge in writing any inaccurate or incomplete information the record might contain, or with which the service recipient disagrees. All Programs must comply with any additional service reporting requirements as outlined in their contracts with PCADV and/or DHS.
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