Pennsylvania Code › Title 55 - HUMAN SERVICES › Part VII - Mental Health Manual › Subpart C - Administration and Fiscal Management › Chapter 5100 - MENTAL HEALTH PROCEDURES › CONFIDENTIALITY OF MENTAL HEALTH RECORDS › Section 5100.31 - Scope and policy

Current through Register Vol. 54, No. 28, July 13, 2024
(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.
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).