Providers must maintain accurate and legible client records. Records must include, at a minimum:
(1) an accurate chronological listing of all substantive contacts with the client;
(2) documentation of services, including:
(i) assessment methods, data, and reports;
(ii) an initial treatment plan and any revisions to the plan;
(iii) the name of the individual providing services;
(iv) the name and credentials of the individual who is professionally responsible for the services provided;
(v) case notes for each date of service, including interventions;
(vi) consultations with collateral sources;
(vii) diagnoses or presenting problems; and
(viii) documentation that informed consent was obtained, including written informed consent documents;
(3) copies of all correspondence relevant to the client;
(4) a client personal data sheet;
(5) copies of all client authorizations for release of information;
(6) an accurate chronological listing of all fees charged, if any, to the client or a third-party payer; and
(7) any other documents pertaining to the client.
If the client records containing the documentation required by subdivision 1 are maintained by the agency, clinic, or other facility where the provider renders services, the provider is not required to maintain duplicate records of client information.
The provider shall retain a client's record for a minimum of seven years after the date of the provider's last professional service to the client, except as otherwise provided by law. If the client is a minor, the record retention period does not begin until the client reaches the age of 18, except as otherwise provided by law.
Official Publication of the State of Minnesota
Revisor of Statutes