The safety, continuity of care and coordination of interdisciplinary treatment for any Hillcrest student depend in part on the accurate and timely documentation of services provided to, and significant events in the student’s life. Effective case documentation also serves to support the student’s treatment plan and effective clinical decision-making, and it constitutes part of the legal record for that student.
Hillcrest utilizes many different forms of case documentation including the Progress Note, an important record written by staff who directly provide care and services to the student. All progress notes at HEC are in electronic form and are accessible through a secure privileging system assigned to clinical and administrative staff. Electronic progress notes are backed up and stored off site on a daily basis. They are periodically archived to DVD media on a yearly basis. Progress notes for, at least, the previous 24 months are always available in the online system.
It is commonly considered to be “best practice” for Progress Notes that, to the extent possible:
• They reflect the chronology or order of service and care events as they happen, and,
• They are written as soon as possible after the service or event, because the closer the documentation is recorded to the actual event, the more accurate and reliable the documentation tends to be.
It is Hillcrest’s policy that, whenever possible, the Progress Note will be entered into the student record on the day or the day following the provision of the service or the occurrence of the event. If circumstances prevent the entry by the end of the day following the provision of the service or the occurrence of the event, the entry is made as soon as possible after that day, and is classified as a late entry.
The following format and protocol are used when making a late entry.
• The current date and time are written in the left hand column.
• The entry begins: “Late entry for (date the service or event occurred)”, followed by the identification of the service or event. For example, “Late entry for 1/24/049. Weekly Individual Therapy x 45 minutes.”

Progress Notes – Time of Day In Progress Notes
Traditionally at Hillcrest we have required that the time of day at which a Progress Note is being written be included under the date of the PN in the left hand margin. However, in addition to sometimes causing confusion (i.e., is it the time the note is written or the time the service was provided?), we have determined that only HEC policy requires this inclusion of the time in the Progress Notes of all disciplines. It is apparently not required by any regulatory agency or accreditation body, and it is not commonly considered standard practice among behavioral health care providers.

Therefore, after consultation with other managers, we have determined that from this point forward, with the exception of Nursing PNs, it will not be necessary to enter the time of day under the date on a PN. Nurses will continue to note the time of day.

Student charts may be “thinned” according to the following guidelines:
• A notice must be placed at the end of the section that has been “thinned” that states, “additional information on this student may be found…” (each campus statement may vary, i.e., one may say on the first shelf in the records room, one may say on the second shelf in the records room, etc.)
• The “thinned” material is placed in a file folder with the student’s name easily visible.
• The “thinned” material is kept in the same room that the original chart is kept to ensure its safety/confidentiality.
• When a student has been discharged from a particular campus, the “thinned” information is integrated back into the student’s original chart before being transferred to another campus or the file being archived.

Thinning of Student Charts

Green Binder:
Face Sheets – keep most recent only.
Preplacement Packet – may remove
after 45 days.

Blue Binder:
Treatment Plans-(IEP/CTP, Quarterlies)-may remove after one year.
Student Contacts – may remove as needed.
Incidents/ PI’s – may remove as needed.
 
Areas that may not be thinned

Green Binder:
Psychiatric
Psychological
Psychosocial
Doctors Orders
Medical Consents
Physical
Dental
Healthcare Services-Eye, Ear, Speech
Neurology
Residential
Nutrition
Physical Therapy
Other Medical Labs
Medication Records
Progress Notes (never remove, never copy)

Blue Binder
Education
Legal
Financial
Correspondence
Discharge

The case record for a student who has been discharged from HEC is stored at the program site for 6 months following the student’s discharge.

The procedures for archiving closed student records are as follows.

• Pull Ed Records (put in manila folder marked “Ed Records” with student’s name on it). Pull CD Rom information – most recent face sheet, most recent psychosocial, immunization record, discharge summary (put in manila folder marked “CD Rom” with student’s name on it). These records will be kept permanently and should be put in a box with other students’ Ed and CD Rom records for archiving. When you have a full box, label accordingly, add to your lists and send to the archive.
• All the rest of the student’s file should be placed in another box. Please put file in manila folders and put the student’s name and discharge date on the side so you can see it when you place the folders in the box. Once you have a full box of files, label accordingly, add to your lists and send to the archive. These files may be destroyed seven (7) years from the date of the most recent student’s discharge date (i.e., if you have four files in a box and discharge dates are 1/00, 2/00, 3/00, 4/00 – the destroy date will be 5/07).
• Send your updated lists to the designated person in Admissions at AO. All campus lists must be in the same format (as per attached – alphabetical list and box list)

Once a month you will receive a Data Storage Warehouse Inventory Report from The Archive. Please review the report for accuracy. If you have any discrepancies, please call The Archive (442-4472) and ask them to fix the error (check your box number, contents, and destroy date).

You may also send other records to be archived – Supes Logs, Travel/Trip Slips, etc. These should also be recorded by campus as “other” files – please do not include with student files (see attached example). This information may be destroyed using the seven (7) year rule as above.

Reference: JC Standard IM.6.10
“The organization has a complete and accurate clinical/case record for every individual assessed, cared for, treated, or served.”
EP 14.
“The retention time of clinical/case record information is determined by the organization
based on law and regulation, and on its use for client care, treatment, and services; legal,
research, and operational purposes; as well as educational activities.”

The case record for a student who has been discharged from HEC is stored at the program site for 6 months following the student’s discharge.

The remaining documentation is then divided and retained as follows:

Kept forever:
One file containing:
All Education Records
One file containing:
Face Sheet
Most recent Psychosocial Summary
Immunization Record
Discharge Summary

The rest of the record is retained in either physical or electronic long-term storage for 7 years after which it is destroyed by an appropriately secure measure (e.g., burning, shredding).

Reference: Joint Commission Standard IM.6.10
“The organization has a complete and accurate clinical/case record for every individual assessed, cared for, treated, or served.”
EP 14.
“The retention time of clinical/case record information is determined by the organization based on law and regulation, and on its use for client care, treatment, and services; legal, research, and operational purposes; as well as educational activities.”

Student records are stored in the records room, which is locked when unattended. The key to the records room is under limited distribution. A staff access log is provided, for noting sign-out and sign-in dates of records. Any record signed out of the records room must be returned immediately following its use. Records may not be signed out overnight. In addition, each student file has an access log for non-staff personnel such as authorized state agency officials requiring the reason for accessing the file. Student files may not leave the campus unless subpoenaed by the court. Parents and students have the same right of access to students’ records as do parents and students of Massachusetts public schools. Electronic progress notes are accessible only through a strict privileging system assigned to clinical and administrative staff. Unauthorized access is a serious matter and is addressed in the Security section of the Employee Policies & Procedures Manual.

1) The privacy and confidentiality of student records at HEC is protected by one of the nation’s strongest privacy and protection laws, the Family Educational Rights and Privacy Act (FERPA). FERPA regulations provide stringent rules regarding a broad range of records and information that encompasses all paper and electronic documents in an educational environment.

All staff members receive specific training regarding the confidential nature of student information during their initial pre-service training and the general staff receive yearly training updates on this subject. Confidentiality of student information is addressed specifically in the Personnel Policies and Procedures in Section 3.8.
The HEC Charts Committee, a standing committee with cross campus and interdisciplinary representation, routinely audits existing charts, communicates procedural policies or changes regarding access to the chart, and facilitates any modification to the structural content of the chart.
Although the FERPA standard does not require specific security routines regarding electronic documentation, the Information Services Department has embraced the computer security requirements found in the Health Insurance and Portability and Accountability Act (HIPAA) and administers strict security access and disaster recovery procedures. Continuity of information is maintained using a comprehensive off-site data warehousing/backup system of mission-critical data and a schedule of routine hardware and software maintenance.
Given that all electronic communication between HEC staff and the agencies they serve is potentially a part of the student record, ALL electronic communication at HEC is archived in real time in a secure facility that meets all Federal , State, and local requirements for secure electronic document storage.

2) Hillcrest Educational Center staff, students and trainees will regard as confidential all information that might identity a person as a HEC client, as well as all information concerning events and conditions as they relate to particular clients. Staff and students will act in every instance to protect such material in accordance with the client’s wishes, and with applicable laws and regulations.
a. Staff are only authorized to see records of clients with whom they are involved in a service or supervisory capacity. Staff may look at other client case records only with the express permission of the client’s Program Director.
b. Case records are the physical and legal property of Hillcrest Educational
Centers, Inc.
Staff will NOT automatically release records when subpoenaed. Instead, staff will check with their Program Directors who, on the basis of possible harm to the client and with the approval of their supervisor, may seek to have the subpoena legally nullified.
Staff will NOT release physical records, electronic records. or components or copies of them to a client, a former client, or to a client or former client’s parent/guardian before securing approval from the Program Director.
c. On each occasion in which a staff removes a client record from either a campus Records Room or from long term storage, the staff must sign out each record being removed, and must sign the record back in upon return to the Records Room or to storage. Staff assumes responsibility for any case record in their possession, and unless they are responding to a court order, and with the knowledge and approval of their Program Director, staff must never remove a client record from a Hillcrest site or property.

Student-specific data and information are contained in the students’ Chart. The Chart exists to facilitate client care, treatment, and services, serve as a financial and legal record, support decision analysis, and guide professional and organization performance improvement. On each HEC campus, student Charts are maintained in a designated secure area. Their access is defined by FERPA regulations and additional guidelines generated by the Chart committee.
Given that HEC is part of the New York State SACWIS system (CONNECTIONS) and anticipates eventual integration with other statewide automated child welfare information systems, the Management team is studying the efficacy of moving to an electronic record system.

HA_Current_Meds_ReEnrollment_Form

HA_MedConsent_Form

HA_OTC_Med_Consent_Form

HA_Re_Enrollment_Form

Pre_Placement_Physical_Form

Immunization_Record_form

Seizure_Report_Form