Children's Targeted Case Management
Practice Guidelines

CONFIDENTIALITY & RECORD-KEEPING

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Confidentiality
Release of Information
Record-Keeping

CONFIDENTIALITY 

Agencies must have a written policy and procedure regarding confidentiality and protocols for record-keeping for children and families.  These policies should describe how and when providers are able to share information. In addition, they must ensure that confidential information about the child and family is protected. Minimally, agency policies and procedures will meet the following standards: 

·        Make every effort to restrict information from being shared for inappropriate purposes and inappropriate situations;

·        Notify families of any potential circumstance in which information may be disclosed without consent; and

·        Whenever possible, make every effort to seek consent from families before disclosing information. 

Suggestions for Best Practices:

·        Engage in conversations about the child and family with professionalism and only in appropriate, relevant settings.

·        Provide the child & family with as much control over their privacy as possible at all times.

·        Before disclosing any private information about a child and family to any external source, be clear about the purpose and goal of that disclosure and ensure that it is in compliance with the HIPAA Privacy Rule.  (See reference below.)

·        Within the office, make reasonable efforts to limit access only to employees who need it as part of their work responsibilities.

·        Provide training to new employees regarding confidentiality and HIPAA compliance.

·        Provide ongoing training regarding confidentiality and HIPAA compliance for all employees as needed.

·        Provide training relating to confidentiality and circumstances with sensitive status, such as HIV and substance abuse. 

(Some of the above information was taken from Gudeman, R., July-September 2003, Journal of the National Center for Youth Law.)

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RELEASE OF INFORMATION 

A release form signed by the parent/guardian, and child when appropriate, is required for all requests for information, whether this release is for information FROM another party or is for information in the child’s file that is to be released TO another party.  

·        Information released will be only what has been designated by the child/parent /guardian and is limited to the specific purpose noted on the release form.

·        Children/Parents/Guardians have the right to review the information being released prior to its release, unless waived.

·        A release of information should be time-limited and specific to its purpose.  Under no circumstance will a release of information be valid for longer than one year.

·        The description of the information and the purpose for which it is being obtained or released must be written clearly on the release form. 

The recipient and the recipient's legally responsible parents, guardians or custodians have the right to review the recipient's record at any reasonable time upon request, including prior to its authorized release.  Rights of Recipients can be accessed at the following website: 

http://www.maine.gov/dhhs/bds/children/Child_index.htm 

Court and legal mandates may require information to be given without consent of the child/parent/guardian. The child/parent/guardian will be informed in writing as soon as possible, except when safety issues or emergency situations exist.  

Agencies must have written procedures delineating compliance with DHHS-CBHS contract stipulations pertaining to the confidentiality of all records and information for children regarding the following: 

·        a child of divorced parents

·        HIV status and test results

·        treatment and diagnosis of drug or alcohol abuse

·        confidentiality as it relates to child abuse and mandated reporting laws

·        use of cellular phones

·        use of fax machines

·        use of electronic mail (email) 

Agencies must have written policies and procedures regarding the protection of confidentiality of each member of a family when the agency is actively involved in case management and/or with other service providers for 1 or more members of the family. Policies and procedures should be consistent with the HIPAA privacy rule.  

 (For more information see:  Summary of the HIPAA privacy rule, HIPAA Compliance Assistance. United States Health & Human Services. OCR Privacy Brief. Website address: http://www.calhipaa.com.)

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RECORD-KEEPING 

Agencies must have written policies and procedures regarding the maintenance, upkeep, and confidential security of the case records.  Case records must be kept in a locked file, withdrawn only by those staff privileged to the information therein, and returned to the locked file at the end of each working day.   

A case record is a unified, comprehensive collection of documentation concerning all services provided to a child.  It includes: 

·        all intake information

·        evaluation(s)

·        assessment(s)

·        level of care determination

·        Individual Support Planning documents

·        any and all written notes regarding the child, the family, or the care provided

·        any and all collateral information regarding the child or the family, including third party payer information; and information about crisis interventions.  

This is a confidential collection of documents.  Only the case manager, his or her supervisor, and other agency staff such as clinical professionals involved in the child’s care, or quality assurance staff, shall obtain information from a case record without the child’s (or guardian’s) prior written consent.

 Any and all information regarding the child is to be kept confidential and secure at all times. 

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