Client Records: Content and Security


Each client, served by a provider contracted with Transformations, will have a standard organized record or chart of documentation of his or her participation in that provider’s service.  The client record shall be considered property of Transformations, who will safeguard it from unauthorized use, access, loss or destruction.   All information is considered confidential and private.


The client record will be initiated upon acceptance of the client.

The accepting provider shall document the acceptance of the client in the client record along with all attempts to set up initial services.

A client health record shall include but not be limited to the following content:

  1. An identification and intake record including:
    1. Name;
    2. Social Security number;
    3. Date of intake;
    4. Home (legal) address;
    5. Health insurance information;
    6. If applicable, the referral source’s name and address;
    7. Primary care physician’s name and address;
    8. The reason the individual is seeking help including the presenting problem and diagnosis;
    9. Any physical health diagnosis, if a physical health diagnosis exists for the individual, and information regarding:      (i) Where the individual is receiving treatment for the physical health diagnosis; and (ii) The physical health provider’s name; and
    10. A consent for treatment sheet that is accurately signed and dated that also includes an acknowledgement of freedom of choice in providers, an informed consent, and understanding of Privacy Practices; and
    11. Copies of any correspondence regarding the client and corresponding signed release of information forms.
  2. Documentation of all services
    1. Signed and dated within 48 hours of the service provided
    2. Screening (if applicable)
    3. Assessment with a complete history including mental status, previous treatment, and the client’s stated purpose for seeking treatment
    4. Treatment plan and a six (6) month review of the plan of care;
    5. Progress notes describing the clients behavior or symptoms as identified on the treatment  plan, the provider’s intervention or service, the client’s attitude and reaction to the intervention or service, any changes to the treatment plan and any need for continued treatment,
    6. Discharge Summary and documentation of the  date and identity of persons receiving the Discharge Summary

A client record shall be furnished upon request to the:Cabinet for Health and Family Services; or for a Medicaid managed care organization or commercial insurance plan in which the recipient is enrolled or has been enrolled in the past;

A client record shall be made available for inspection and copying by: the Cabinet for Health and Family Services’ personnel; or personnel of the Medicaid managed care organization or commercial insurance plan in which the recipient is enrolled if applicable;

A client record shall be readily accessible through the agency’s electronic medical record system.

Transport of any records must follow the double lock security standard, i.e. in a locked brief case in a locked vehicle trunk and/ or in a password protected computer with a password protected secure electronic medical records system.

Records of discharged clients shall be retained and stored in a secured setting.  Paper charts shall be stored with a professional medical record storage facility and electronic records shall be stored in a double locked secure system.

Client records and documentation are considered the property of the agency.

Client records shall be destroyed:

  1. Five (5) years after the discharge or death of the client unless the client is a minor; or until an audit dispute or issue is resolved beyond the five years.
  2. or If the client is a minor, at least three (3) years after the client reaches the age of majority under state law unless five years is longer.
  3. If the Secretary of the United States Department of Health and Human Services requires a longer document retention period, the period established by the secretary shall be the required period.

In the event that the agency ceases to operate, all records shall be transferred to the care and custody of the agency owner, Teresa Lloyd.

Resources and Links:

907 KAR 15:010 Records Maintenance, Documentation, Protection, and Security

907 KAR 15:060 Records Maintenance, Documentation, Protection, and Security

Revised : 10-23-2018