Ariz. Admin. Code § 4-6-1103

Current through Register Vol. 30, No. 45, November 8, 2024

Section R4-6-1103 - Client Record

A. A licensee shall ensure that a client record is maintained for each client and:

1. Is protected at all times from loss, damage, or alteration;

2. Is confidential;

3. Is legible and recorded in ink or electronically recorded;

4. Contains entries that are dated and include the printed name and signature or electronic signature of the individual making the entry;

5. Is current and accurate;

6. Contains original documents and original signature, initials, or authentication; and

7. Is disposed of in a manner that protects client confidentiality.

B. A licensee shall ensure that a client record contains the following, if applicable:

1. The client's name, address, and telephone number;

2. Information or records provided by or obtained from another person regarding the client;

3. Written authorization to release the client's record or information;

4. Progress notes;

5. Informed consent to treatment;

6. Contemporaneous documentation of:

a. Treatment plan and all revisions to the treatment plan;

b. Requests for client records and resolution of the requests;

c. Release of any information in the client record;

d. Contact with the client or another individual that relates to the clients health, safety, welfare, or treatment; and

e. Behavioral health services provided to the client;

7. Other information or documentation required by state or federal law.

8. Financial records, including:

a. Records of financial arrangements for the cost of providing behavioral health services;

b. Measures that will be taken for nonpayment of the cost of behavioral health services provided by the licensee.

C. A licensee shall make client records in the licensee's possession promptly available to another health professional and the client or the client's legal representative in accordance with A.R.S. § 12-2293.

D. A licensee shall make client records of a minor client in the licensee's possession promptly available to the minor client's parent in accordance with A.R.S. § 25-403.06.

E. A licensee shall retain records in accordance with A.R.S. § 12-2297.

F. A licensee shall ensure the safety and confidentiality of any client records the licensee creates, maintains, transfers, or destroys whether the records are written, taped, computerized, or stored in any other medium.

G. A licensee shall ensure that a client's privacy and the confidentiality of information provided by the client is maintained by subordinates, including employees, supervisees, clerical assistants, and volunteers.

H. A licensee shall ensure that each progress note includes the following:

1. The date a behavioral health service was provided;

2. The time spent providing the behavioral health service;

3. If counseling services were provided, whether the counseling was individual , couples, family, or group; and

4. The dated signature of the licensee who provided the behavioral health service.

Ariz. Admin. Code § R4-6-1103

New Section made by exempt rulemaking at 10 A.A.R. 2700, effective July 1, 2004 (Supp. 04-2). Amended by exempt rulemaking at 21 A.A.R. 2630, effective 11/1/2015.