This request for assistance is directed to those agencies that create
and maintain clinical treatment records and referrals to treatment
services, particularly Community Services Boards.

 

The LVA Retention Schedule GS-18 separates Client Case Files and
Prescreening Reports (referrals) into two distinctly different types of
records with different retention periods (6 years vs 2 years).  Referral
forms are typically integrated into the Client Case File once the client
enters services.  

 

My question is this.  How do agencies handle client referral forms that
come in after the client's Case File has been closed to the agency for a
number of years (i.e. no services) but not long enough for the Case File
to have been destroyed and the client does not show up or enroll in any
services as a result of this recent referral?  In other words, we have a
referral on a former client whose closed or inactive Case File is about
6 years old and ready for destruction.  

 

Our clinicians want to incorporate or file those referral forms into the
closed Client Case File making them part of the Case File for historical
purposes. That Case File may be 6 years since date of last service and
ready for destruction but once this new referral form is filed in the
Case File would this extend the retention period another 6 years, even
though the client never enrolled in a service (we do not consider a
referral as a service)?

 

We use date of last service to determine when we can destroy a Case File
but if we file a Referral Form in a closed Case File it appears the
client has a recent activity when in fact the client never enrolled in a
service.  The date of last service in our MIS system used to make our
calculation for destruction and the information in the Case File with
the recently received Referral Form seems now to be in conflict.

 

Any information on how other agencies handle this would be greatly
appreciated.

 

Thanks.

 

Max

 

 

Max Dean

Mount Rogers Community Services Board

Data Resources Office

770 West Ridge Road

Wytheville, Va.  24382

(276) 223-3215 (Phone)

(276) 223-3250 (Fax)

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Visit us on the web at www.mtrogerscsb.com

 

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