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12VAC5-381-280 — Client record system

VirginiaregulationVirginia Department of Health, Office of Licensure and Certification· effective 2006-01-01

What this rule requires your agency to do

  • 1Provide for safe storage of the original record and for accurate, legible reproductions (subsection D).(12VAC5-381-280 — Client record system)
  • 2Specify by policy the arrangements for retention/protection of records if the organization discontinues operation, including notification to the OLC and the client of the records' location (subsection E).(12VAC5-381-280 — Client record system)
  • 3Maintain an accurate, complete client record for each client including the enumerated contents (identifying info, primary care physician, admitting/history, household composition, initial assessment, plan of care/service, client-rights review documentation, and discharge/termination summary), plus the additional skilled/pharmaceutical contents where applicable (subsection F).(12VAC5-381-280 — Client record system)
  • 4Ensure signed and dated service notes are written on the day the service is delivered and incorporated into the client record within seven working days (subsection G).(12VAC5-381-280 — Client record system)
  • 5Safeguard client record information against loss or unauthorized use, keep records confidential, and limit access to authorized personnel as specified by state and federal law (subsections B, C).(12VAC5-381-280 — Client record system)
  • 6Maintain an organized client record system per accepted standards of practice, with written policies specifying retention, reproduction, access, storage, content, and completion of the record (subsection A).(12VAC5-381-280 — Client record system)
  • 7Ensure entries are current, legible, dated, and authenticated by the person making the entry, with errors corrected by striking through and initialing (subsection H).(12VAC5-381-280 — Client record system)
  • 8Maintain original or reproduced client records in their entirety for a minimum of five years following discharge or date of last contact (records of minors kept at least five years after the minor reaches age 18) unless otherwise specified by state or federal requirements (subsection I).(12VAC5-381-280 — Client record system)

Applies to: personal care

Requires a home care organization to maintain an organized, confidential, secure client record system with policies on retention, access, storage, and content; specifies the required contents of each client record (including plan of care, client-rights documentation, and skilled/pharmaceutical add-ons); requires timely, authenticated entries; and sets a minimum five-year record retention period. Framework topic: Clinical Operations / Client Records & Documentation.

Regulatory information, not legal advice — always confirm against the cited official source. Verification reduces error; it does not certify compliance.