Client Records
Each client will have a Client Chart established before receiving treatment or assessment. Clients also may have video or audio records.
Chart Access:
- Active client charts are kept in the Files Room 156A, in the Clinic Secretary´s office. The door to this room is to remain closed at all times.
- Files are arranged in alphabetical order.
- To check out a client chart: Use the orange OUT cards, located in the front of the file drawer. Fill out the card and insert it in the place of the chart you removed. This is necessary for tracking the location of charts at all times.
- To return a client chart: Return the chart to the file cabinet. Return the OUT card to the front of the file cabinet.
- The charts of former clients are stored by case history number. When clinic space does not allow all client charts to be maintained in the clinic, the oldest clinic charts will be stored in UMD archives.
Chart Safeguarding:
- Information contained within the clinical records is personal and confidential.
- Clinic record information is not to be released without written consent from the client or guardian, using the Consent to Release Private Data
- Client charts may not be removed from the Clinic.
- If a student violates client confidentiality in any manner, the student´s clinic practicum grade will be lowered, the student may be dismissed from practicum, the student may be found in violation of HIPAA, and subject to University, state, and federal penalties.
Chart Organization:
Each client chart will include the following information, organized in the following manner:
Chart Organization
| SECTION |
CHART CONTENTS |
| Inside front cover |
- Enrollment Information Form, updated each semester
- Summary of Service Sheet, updated throughout the semester with the following information:
- Date treatment started for the semester
- Family/client initial staffing
- Referrals
- Request for records from other agencies
- Release of information to other agencies
- Hearing screenings
- Phone contacts
- Testing
- Family/client final staffing
- Last date of treatment for the semester
|
| Section I |
- RFP Clinic Semester Treatment Summary Reports, organized chronologically with the most current report on top.
- Most recent RFP Semester Treatment Plan and Progress Notes.
|
| Section II |
- Audiological Information, organized chronologically with the most current report on top.
- RFP Clinic Audiological Assessment Reports
- RFP Clinic Hearing Screenings (must be updated annually)
|
| Section III |
- RFP Clinic Speech & Language Diagnostic Assessment Reports
- Records from Other Agencies
|
| Section IV |
- RFP Clinic Payment Agreement Form
- RFP Clinic Fee Support Application Form (if client applied)
|
| Section V |
- RFP Clinic Consent & Release Forms
|
| See Appendix to view each of these forms. |
|
Video and Audio Records
The RFP Clinic has a digital recording system with a central storage system. The Clinic also has a number of hand digital cameras and cassette players available for recording. All visual and audio recordings are Private Health Information (PHI).
Centrally stored digital recording
Recordings using the clinic's digital recording system will be stored on a central server. Students can access the recordings from computers in the CSD Computer Lab.
Audiovisual data from handheld cameras and audiocassette recordings
Audiovisual data recorded onto cassettes , CDs, DVDs or jumpdrives must be stored in the Clinic Files Room 154A, in the AV Records File under the specific client's name. The cassettes, CDs, DVDs, or jumpdrives must be clearly marked with the client's name, date of birth, chart number, and date of recording. Recordings may be viewed or listened to ONLY in the CSD Department, and may not be taken out of the Department.
All recordings are kept only for one semester. In the event a student or faculty member wishes to keep a recording for educational purposes, they recording may be archived. Please talk with the clinic secretary in the event you wish for a file to be archived.
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