10A NCAC 26B .0106      ALTERATIONS IN THE CLIENT RECORD

A client or a client's legally responsible person may contest the accuracy, completeness or relevancy of information in the client record and may request alteration of such information.  Alterations shall be made as follows:

(1)           whenever a clinical staff member concurs that such alteration is justified, the area or state facility shall identify the contested portion of the record and allow the insertion of the alteration as an addendum to the contested portion of the client record; however, the original portion of the written record may not be deleted; or

(2)           whenever a clinical staff member does not concur that such alteration is justified, the area or state facility shall identify the contested portion of the record and allow a statement relative to the contested portion to be added to the client record which shall be recorded on a separate form and not on the original portion of the record which is being contested.  Such statement shall be made a permanent part of the client's record and shall be released or disclosed along with the contested portion of the record.

History Note:        Authority G.S. 122C‑52; 122C‑53; 131E‑67; 143B‑147(a)(6);

Eff. July 1, 1979;

Amended Eff. March 1, 1990; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. June 20, 2015.