II.N REQUEST FOR RECORDS

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Wed, 05/27/2015
Revised: 
Wed, 05/27/2015
Policy: 

Clients are entitled to receive or review their record when this is "in their best interests" and would not be likely to cause "substantial harm."  The clinician reviews the record to determine if anything in it would, in her/his judgment, likely cause "substantial harm" as indicated by tangible and serious negative outcome, e.g. injury to self or others, not just emotional upset. Records are released in accordance with professional standards and regulatory guidelines.

Procedure: 

1. If a client requests a copy of their record they must follow the procedures listed below:

i.       The client is required to request the records in writing and must sign a release of information form.

ii.      CAPS will, if appropriate, provide the client with a summary of their records or the entire record if requested.

iii.    If providing the records is deemed inappropriate CAPS will, after court order or request of the client, forward a copy of the records to a licensed mental health professional designated by the client

If the likelihood of harm as a result of disclosure may not be satisfactorily addressed through a staff person reviewing the records with the individual then:

1.)     The denial and reasons for it are reviewed with the individual; and

2.)     The denial and reasons for it are noted in the individual's record.

iv.     If a client wishes to see their records after they have read the summary and it is deemed appropriate for them to do so they may read the file in the presence of the CAPS Director or designee.  A copy of the file may be made at the client's expense.

2. Time guidelines for release of records:

i. Review of records-Five working days

ii. Treatment summary-Ten working days

iii. Copy of records-Fifteen calendar days

iv. Complex treatment summary-Thirty calendar days