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Title 7 . Health and Social Services
Chapter 71 . Assisted Living Homes
Section 155. Client records

7 AAC 71.155. Client records

(a) A center must maintain an organized record system that contains client information, including information required on the admission and discharge forms provided by the department.

(b) A client record must contain documentation of the initial and continued assessment of the client including

(1) a description and evaluation of the present problem as seen by the client;

(2) a mental status assessment;

(3) health status and current medication;

(4) developmental, social, and referral information; and

(5) a diagnostic formulation of the client's problems.

(c) A client record must contain an identifiable, current treatment plan which includes

(1) the goals of the service provided by the center;

(2) a description of the services to be provided and the frequency and estimated duration of these services; and

(3) copies of referrals to other individuals or agencies to meet these service goals when referrals are necessary.

(d) A client record must contain descriptive progress notes including all diagnostic and treatment services rendered and their results.

(e) A client record must be dated and signed by the person completing it.

(f) A client record must contain a closing summary at termination of service which must include the reason for termination, a summary of the course and results of treatment, and any follow-up plans or referral information.

(g) A center must provide for at least semi-annual utilization review of client records to determine that the records contain sufficient documentation to meet the requirements of this section.

(h) A center must submit information to the department as required by 7 AAC 85.

(i) Subject to the other provisions of this subsection, a center may satisfy the recordkeeping requirements of this section for records that contain behavioral health information through electronic records that meet the applicable requirements of 7 AAC 85. Notwithstanding the requirements of this section, a center may be required to retain paper or paper-based copies of documents that are required under other state or federal law for audit or other purposes. For purposes of this subsection,

(1) "behavioral health information" means information regarding behavioral health services, including

(A) emergency services, including detoxification and acute psychiatric hospitalization; and

(B) prevention, intervention, and treatment services in the areas of mental health and of alcohol abuse and other addictions, including ongoing care and supportive services; and

(2) "paper-based copies" means documents stored on microfilm or microfiche, in tagged image file format (TIFF), portable document file (PDF) format, or in another format that allows for the efficient storage of documents.

History: Eff. 9/1/82, Register 83; am 11/29/97, Register 144; am 6/24/2004, Register 170; am 9/23/2004, Register 171

Authority: AS 18.23.100

AS 47.30.530

AS 47.30.540


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Last modified 7/05/2006