This regulation requires license holders providing substance use treatment or detoxification services to maintain current client records on-site, with each entry signed and dated. Records must be protected against loss, tampering, and unauthorized disclosure per applicable state and federal privacy laws. Discharged client records must be retained for seven years, and if a facility closes, the commissioner must be notified of record storage location and custodian. Required record contents include presenting problem documentation, chemical use screening, assessments, abuse prevention plans, referral documentation, and health observation notes.
View official source9530.6585 CLIENT RECORDS. § Subpart 1. Client records required. A license holder must maintain a file of current client records on the program premises where the treatment is provided. Each entry in each client case record must be signed and dated by the staff member making the entry. Client records must be protected against loss, tampering, or unauthorized disclosure in compliance with Minnesota Statutes, section 254A.09 ; Code of Federal Regulations, title 42, chapter 1, part 2, subpart B, sections 2.1 to 2.67, and Code of Federal Regulations, title 45, parts 160 to 164, and Minnesota Statutes, chapter 13. § Subp. 2. Records retention. A license holder must retain the records of discharged clients for seven years, unless otherwise required by law. A license holder that ceases providing treatment or detoxification services must retain client records for seven years from the date the facility closed. The license holder must notify the commissioner of the location of the records and the name, address, and telephone number of a person responsible for maintaining the records. § Subp. 3. Contents of records. Client records must include the following: § A. documentation of the client's presenting problem, any chemical use screening, the most recent assessment, and any updates; § B. an individual abuse prevention plan that complies with Minnesota Statutes, section 245A.65 , and related rules; § C. documentation of referrals made according to part 9530.6530 ; and § D. documentation of observations as required by part 9530.6550 .