SAMPLE POLICY WORK

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Individual Support Plans (ISPs): Comprehensive care plans that outline client ‑ specific goals, required services, interventions, and measurable outcomes. Progress and Service Notes: Daily logs, progress reports, and notes detailing every interaction, service rendered, and any incident with the client. Medical and Health Records: Documentation of client medical history, treatment plans, medication administration records (MARs), and emergency assessments. Correspondence and Consent Forms: All signed consent forms, forms of authorization, and correspondence between staff, clients, and their families. Regulatory and Audit Documents: Copies of regulatory submissions, internal audit reports, and any related external compliance documentation.

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Procedural Guidelines for Client Files

Creation:

– Upon client intake, an electronic client file is created immediately in the centralized digital records system. – All initial records (e.g., assessments, consent forms) are scanned and uploaded, with each document assigned a digital timestamp. 2. Maintenance: – Every interaction, subsequent assessment, and care interaction input must be updated in real time. – Staff are required to complete daily logs within 24 hours of service delivery, ensuring that no data is delayed or omitted. 3. Security and Confidentiality: – Client files are stored in an encrypted digital environment with role ‑ based access controls. – Only authorized personnel are granted access, and every access is logged in an automatic audit trail. 4. Record Retention: – Client files are retained for a minimum duration of seven years following the termination of services, as required by state and federal guidelines. 5. Record Destruction:

– Upon expiration of the retention period, documents are securely destroyed using approved methods (e.g., shredding, secure digital deletion).