<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".15" citation="COMAR 13A.11.08.15" title_num="13A" subtitle_num="11" chapter_num="08" heading="Records.">
  <paragraph num="A.">
    <text>The Director shall assure that policies and procedures are developed and maintained to ensure that a confidential record, including electronic and hard copy, is established and maintained for each client admitted to the Center.</text>
  </paragraph>
  <paragraph num="B.">
    <text>The record for each client shall include:</text>
    <paragraph num="(1)">
      <text>Case identification data;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Pertinent history, diagnosis of disability, functional limitation or limitations, and goals;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Reports of assessment and individual program planning;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Reports from referring sources;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Reports of staff conferences;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>The individual service plans;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>Signed and dated service and progress reports from each Center department providing service;</text>
    </paragraph>
    <paragraph num="(8)">
      <text>Release forms;</text>
    </paragraph>
    <paragraph num="(9)">
      <text>Reports from outside consultation including laboratory, radiology, medical, or related services;</text>
    </paragraph>
    <paragraph num="(10)">
      <text>Designation of the case manager for the client;</text>
    </paragraph>
    <paragraph num="(11)">
      <text>Evidence of the client's, and when appropriate, the family's participation in the decision-making process of the client's program;</text>
    </paragraph>
    <paragraph num="(12)">
      <text>Discharge information; and</text>
    </paragraph>
    <paragraph num="(13)">
      <text>Other information relating to the planning, provision, and management of services to the client.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>The Center record shall be retained for a minimum of 5 years from the time the client is discharged from the Center.</text>
  </paragraph>
  <paragraph num="D.">
    <text>The record shall be maintained in a secure area and may be disclosed to the client, the client's representative, or others only in accordance with the standards set forth in COMAR 13A.11.06.</text>
  </paragraph>
  <paragraph num="E.">
    <text>The record may not be removed from the Center unless by court order or with the permission of the Director or Director's designee.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Staff members of the Center or the Division who are involved in providing rehabilitation services to a client may maintain a working file relating to the client for their own use in planning, implementing, and managing the services, provided that these files are maintained in a secure place and are not accessible to or revealed to any other person, except in accordance with the standards of COMAR 13A.11.06.</text>
  </paragraph>
</regulation>