An Oregon Medicaid Agency Supporting Individuals with Intellectual and Developmental Disabilities

Section 7

Record Keeping

Disclosure of Records

The Company records regarding services for customers are to be kept confidential in accordance with Oregon state statutes, the federal Health Insurance Portability and Accountability Act (HIPAA), and any other state administrative rules related to individual service records.

A customer’s non-medical personal information must remain confidential in accordance with the “personal privacy information” exemption to the state’s public records law, as outlined in ORS192.502(2).

This states that information of a personal nature (such as the information kept in personal, medical or similar files) cannot be released if making it public would constitute an unreasonable invasion of privacy. There is an exemption if the public interest, by clear and convincing evidence, can show that disclosure is required in a particular instance. The party asking for disclosure has the burden of showing that public release would not constitute an unreasonable invasion of privacy.

ODD may access a customer’s records without authorization from the individual or their family.

Retention of Records

Individual customer records are kept by the Company for a minimum of seven years. The Company’s contracts and financial records are to be retained for a minimum of four years.

Protection of Records

All employees are responsible for protecting customer information. This includes not revealing any information about the Company’s on-line record-keeping services like the Company’s proprietary billing and progress notes system.

Logging into the progress notes system requires various levels of security. These include:

  • The URL of the system.
  • The Company’s username and password.
  • The employee’s username and password.
  • The employee’s PIN number.

The employee shall memorize these items and never write them on a note pad or piece of paper, leave them in a computer file, or verbally reveal them to anyone.

The employee should never log in while another person is watching. The employee should keep all devices secure by passwords, fingerprints, or codes when not being used.

Employee mobile devices that are used to access the program must never be loaned to a family member or other individual.

Billing and Progress Notes

The Company has a proprietary billing and progress notes system that tracks sessions with customers, including start/stop times, non-medical transportation miles, GPS coordinates at start/stop times of service delivery, and progress notes. There are both external progress notes and internal progress notes.

External progress notes are notes about service delivery that are intended for reporting progress to case management CDDP and ODDS. Internal progress notes are information that needs to be kept by the Company for later review in the event the information is needed.

Each employee will begin each session with a customer by logging into the billing program and starting a session with the client at the precise minute the session begins. Each employee will end each session with a customer by logging into the billing program and ending the session with the client at the precise minute the session ends. In the event that the billing program is not available at these times, the start and/or stop times may be recorded or edited later, but the employee must enter a reason for not recording at the time of service delivery.

The Company considers it best practice to work on external progress in collaboration with the customer to allow the customer to see their own progress and plan accordingly. The employee should engage the customer in collaborating on writing notes before logging an end time for services delivered.

Employees who chronically forget to record delivery of service on time may be subject to disciplinary action, including for-cause termination.

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