Pa. Code 5100.31

Scope and policy

This section establishes the scope and confidentiality policy for records of persons seeking, receiving, or having received mental health services from any facility as defined under Pennsylvania's Mental Health Procedures Act. It requires mental health facilities to treat client/patient records with confidentiality, inform current clients of any applicable limits on confidentiality, and make good-faith efforts to notify discharged patients before releasing their records pursuant to legal mandates. Patients generally retain control over the release of information in their records, subject to specific exceptions for nonconsensual disclosure outlined in companion sections.

55 Pa. Code § 5100.31 - Scope and policy 

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(a)
 This chapter
 applies to records of persons seeking, receiving or having received mental
 health services from any facility as defined in section 103 of the act
 (
50
 P. S. §
 
7103
).

(b)
 Persons seeking or receiving services
 from a mental health facility are entitled to do so with the expectation that
 information about them will be treated with respect and confidentiality by
 those providing services. Confidentiality between providers of services and
 their clients is necessary to develop the trust and confidence important for
 therapeutic intervention. While full confidentiality cannot be guaranteed to
 everyone as a result of Federal and State statutes which require disclosure of
 information for specific purposes, it remains incumbent upon service providers
 to inform each current client/patient of the specific limits upon
 confidentiality which affect his treatment when these limits become applicable.
 When facilities are required by Federal or State statutes or by order of a
 court to release information regarding a discharged patient, a good faith
 effort shall be made to notify the person by certified mail to the last known
 address.

(c)
 As used in this
 chapter, "records" includes, but is not limited to, all written clinical
 information, observations and reports or fiscal documents, relating to a
 prospective, present or past, client or patient, which are required or
 authorized to be prepared by the act or by the Mental Health and Mental
 Retardation Act of 1966. This includes any central file of client/patient
 records and reports which are required to be maintained by the Department's
 regulations or other statutes and regulations regarding service content for
 mental health programs. Every therapist who reports objective findings must
 carefully consider the impact of placing in the records statements made
 privately in therapy sessions.

(d)

 Nothing in this chapter shall limit the facility's obligation to attempt to
 obtain social history and other records necessary to properly treat an
 involuntarily committed patient, or to obtain information on financial
 resources or insurance coverage necessary to determine the liability for
 services rendered.

(e)
 This section
 applies to all records regarding present or former patients of mental health
 facilities, including records relating to services provided under previous
 mental health acts.

(f)
 Records of a
 person receiving mental health services are the property of the hospital or
 facility in which the person is or has received services. The person who is or
 was receiving services shall exercise control over the release of information
 contained in his record except as limited by §
 
5100.32
 (relating to nonconsensual
 release of information), and be provided with access to the records except to
 the limitations under §
 
5100.33
 (relating to patient's
 access to records and control over release of records).

(g)
 The presence or absence of a person
 currently involuntarily committed at a mental health facility is not to be
 considered a record within the meaning of subsection (c) and such information
 may be released at the discretion of the director of a facility in response to
 legitimate inquiries from governmental agencies or when it is clearly in the
 patient's best interest to do so.

(h)
 No document which was a public record
 prior to the person's treatment shall become confidential by its inclusion in
 the facility's records.

(i)
 When
 information and observations regarding clients or patients are not made part of
 a record, there remains a duty and obligation for staff to respect the
 patient's privacy and confidentiality by acting ethically and responsibly in
 using or discussing such information.

Notes

55

 Pa. Code §
 
5100.31

This section cited in 55 Pa. Code §
 
3800.20
 (relating to
 confidentiality of records); 55 Pa. Code §
 
5100.4
 (relating to scope); 55 Pa.
 Code §
 
5100.33
 (relating to patient's
 access to records and control over release of records); 55 Pa. Code §
 
5200.47
 (relating to other
 applicable regulations); 55 Pa. Code §
 
5210.26
 (relating to records); 55
 Pa. Code §
 
5210.56
 (relating to other
 applicable regulations); 55 Pa. Code §
 
5221.52
 (relating to notice of
 confidentiality and nondiscrimination); 55 Pa. Code §
 
5230.17
 (relating to
 confidentiality); and 55 Pa. Code §
 
5320.26
 (relating to
 confidentiality).

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