§ 5100.31. Scope and policy.

 (a)  This chapter applies to records of persons seeking, receiving or having received mental health services from any facility as defined in section 103 of the act (50 P. S. §  7103).

 (b)  Persons seeking or receiving services from a mental health facility are entitled to do so with the expectation that information about them will be treated with respect and confidentiality by those providing services. Confidentiality between providers of services and their clients is necessary to develop the trust and confidence important for therapeutic intervention. While full confidentiality cannot be guaranteed to everyone as a result of Federal and State statutes which require disclosure of information for specific purposes, it remains incumbent upon service providers to inform each current client/patient of the specific limits upon confidentiality which affect his treatment when these limits become applicable. When facilities are required by Federal or State statutes or by order of a court to release information regarding a discharged patient, a good faith effort shall be made to notify the person by certified mail to the last known address.

 (c)  As used in this chapter, ‘‘records’’ includes, but is not limited to, all written clinical information, observations and reports or fiscal documents, relating to a prospective, present or past, client or patient, which are required or authorized to be prepared by the act or by the Mental Health and Mental Retardation Act of 1966. This includes any central file of client/patient records and reports which are required to be maintained by the Department’s regulations or other statutes and regulations regarding service content for mental health programs. Every therapist who reports objective findings must carefully consider the impact of placing in the records statements made privately in therapy sessions.

 (d)  Nothing in this chapter shall limit the facility’s obligation to attempt to obtain social history and other records necessary to properly treat an involuntarily committed patient, or to obtain information on financial resources or insurance coverage necessary to determine the liability for services rendered.

 (e)  This section applies to all records regarding present or former patients of mental health facilities, including records relating to services provided under previous mental health acts.

 (f)  Records of a person receiving mental health services are the property of the hospital or facility in which the person is or has received services. The person who is or was receiving services shall exercise control over the release of information contained in his record except as limited by §  5100.32 (relating to nonconsensual release of information), and be provided with access to the records except to the limitations under §  5100.33 (relating to patient’s access to records and control over release of records).

 (g)  The presence or absence of a person currently involuntarily committed at a mental health facility is not to be considered a record within the meaning of subsection (c) and such information may be released at the discretion of the director of a facility in response to legitimate inquiries from governmental agencies or when it is clearly in the patient’s best interest to do so.

 (h)  No document which was a public record prior to the person’s treatment shall become confidential by its inclusion in the facility’s records.

 (i)  When information and observations regarding clients or patients are not made part of a record, there remains a duty and obligation for staff to respect the patient’s privacy and confidentiality by acting ethically and responsibly in using or discussing such information.

Cross References

   This section cited in 55 Pa. Code §  3800.20 (relating to confidentiality of records); 55 Pa. Code §  5100.4 (relating to scope); 55 Pa. Code §  5100.33 (relating to patient’s access to records and control over release of records); 55 Pa. Code §  5200.47 (relating to other applicable regulations); 55 Pa. Code §  5210.26 (relating to records); 55 Pa. Code §  5210.56 (relating to other applicable regulations); 55 Pa. Code §  5221.52 (relating to notice of confidentiality and nondiscrimination); 55 Pa. Code §  5230.17 (relating to confidentiality); and 55 Pa. Code §  5320.26 (relating to confidentiality).

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