POPS Chapter 14 – Client File Organization, Content, and Security Standards
Subchapters
14.1 Client File Organization
The agency uses an organized system for arranging materials in client files that is consistent throughout all files.
The following documents/information are easily accessible in each client file:
- Signed client intake/application for services
- Intake/eligibility forms and documents
- Authorization for release of confidential client information (when appropriate)
- Consent for disclosure on receipt of confidential client information (when appropriate)
- Signed consent to receive services and emergency notification
- Client assessment and service plan
- Signed confidentiality form
- Proof of HIV positivity and Western Blot laboratory record, including client name or verification from a physician containing the client’s name)
- Proof of income (where necessary to decide eligibility of client)
- Proof of Texas residency
- Information about health care providers
- Information about health care coverage (e.g., insurance, Medicaid, Medicare, etc. ...)
- Signed Client Bill of Rights or signed acknowledgment of receipt of document
- Signed acknowledgment of receipt of grievance rights
- Systematic documentation of case management activity and services provided
- Documentation of referrals made or received and tracking of those referrals
HOPWA documents, if applicable:
- Application for Housing Assistance
- Client Statistics Form
- Emergency Assistance Program – Allowable Assistance Worksheet
- Rental Assistance Program – Allowable Assistance Worksheet
- Gross Income Worksheet
- Adjusted Income Worksheet
- Gross Income Exclusions
- Termination Form
- Lease and information about where to send rent payments
- Documentation of utility bills
- Regular updates of the above information as changes occur or as needed
14.2 Client File Security
Client files are kept in locked file cabinets and stored in a secure area of the agency’s building
- Files that are not in use or are left unattended should be locked. All files should be locked during non-working hours and the program manager should designate persons responsible for securing records at closing time
- When client files are removed from file cabinets for work purposes, they are handled in a manner to ensure that only authorized personnel have access to them
- There are policies/procedures that limit access to client files to authorized personnel
- Access to computers containing confidential records should be restricted in a manner identical to that described for files
- Electronic records which contain information that includes client identity (e.g., case management records) have adequate safe guards to prevent unauthorized access to this information