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PDFWAC 246-341-0425

Agency administrationIndividual service record system.

Each behavioral health agency must:
(1) Maintain a comprehensive individual service record system that includes policies and procedures that protect an individual's personal health information;
(2) Ensure that the individual's personal health information is shared or released only in compliance with applicable state and federal law;
(3) If maintaining electronic individual service records:
(a) Provide secure, limited access through means that prevent modification or deletion after initial preparation;
(b) Provide for a backup of records in the event of equipment, media, or human error;
(c) Provide for protection from unauthorized access, including network and internet access;
(d) Provide that each entry made in an individual's individual service record clearly identifies the author and who approved the entry, if applicable; and
(e) Prohibit agency employees from using another employee's credentials to access, author, modify, or delete an entry from an individual's individual service record;
(4) Retain an individual's individual service record, including an electronic record, for a minimum of six years after the most recent discharge or transfer of any individual;
(5) Retain a youth's or child's individual service record, including an electronic record, for at least six years after the most recent discharge, or until the youth's or child's 21st birthday, whichever is longer;
(6) Ensure secure storage of active or closed confidential records;
(7) When providing access to individual service records to an individual, the agency must allow appropriate time and privacy for the individual to review the records and have a clinical staff member available to answer questions;
(8) If the agency maintains electronic health records, the agency must make the records available to requestors in hard copy form;
(9) The agency must allow the department access to individual service records; and
(10) When an individual receiving services is under the supervision of the department of corrections (DOC), the agency must make information available to DOC, in accordance with RCW 71.05.445. The information released does not require the consent of the individual except as restricted by federal law or regulation.
[Statutory Authority: RCW 71.24.037, 71.05.560, 71.34.380, 18.205.160, 43.70.080(5), 41.05.750, 43.70.250, 74.09.520, and chapters 71.05, 71.12, 71.24, and 71.34 RCW. WSR 22-24-091, § 246-341-0425, filed 12/6/22, effective 5/1/23. Statutory Authority: RCW 71.24.037, 71.05.560, 71.34.380, 18.205.160, 71.24.037 and chapters 71.05, 71.24, and 71.34 RCW. WSR 21-12-042, § 246-341-0425, filed 5/25/21, effective 7/1/21. Statutory Authority: 2018 c 201 and 2018 c 291. WSR 19-09-062, § 246-341-0425, filed 4/16/19, effective 5/17/19.]
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