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Defines the CAP-MR/DD services and the role of Local Management Entities in managing service records. Establishes general records administration and reporting obligations, including personnel records, indices, retention and disposition schedules, record transfer when an LME dissolves or merges, and administrative signature files. Specifies documentation and coordination requirements for screening, triage, referral, registration, admission, discharge, reporting systems, incident and death documentation, and clinical service record structure, privacy, security, and closure processes.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":40,"@type":76,"position":81},"https://docshare.wps.com/document/research-report/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/records-management-and-documentation-manual-providers-of-publicly-funded-mhddsa-services/646255/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/records-management-and-documentation-manual-providers-of-publicly-funded-mhddsa-services/646255.png","ImageObject",300,407,{"name":92,"@type":93},"QWQ","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-24","2026-10-23",true,{"@type":102,"interactionType":103,"userInteractionCount":8},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Who is this manual intended for?","Question",{"text":112,"@type":113},"It is for providers of publicly-funded MH/DD/SA services, covering CAP-MR/DD services and Local Management Entities in North Carolina.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What general records administration topics does Chapter 1 cover?",{"text":117,"@type":113},"Chapter 1 covers the value of recordkeeping, administrative requirements (including personnel records, indices, and retention/disposition), LME and provider responsibilities, record transfer during LME dissolution or merger, and data reporting requirements.",{"name":119,"@type":110,"acceptedAnswer":120},"What does Chapter 2 specify about clinical service records?",{"text":121,"@type":113},"Chapter 2 defines the purpose and importance of clinical documentation, outlines types of clinical service records and the contents of a full clinical service record, and addresses closure, privacy, and security of service records.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},646255,1792811137,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":39,"category_name":40,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":8,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":145},962094510011,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","| \u003Cbr>RECORDS MANAGEMENT AND DOCUMENTATION MANUAL\u003Cbr>for\u003Cbr>Providers of Publicly-Funded MH/DD/SA Services\u003Cbr>CAP-MR/DD Services\u003Cbr>and\u003Cbr>Local Management Entities\u003Cbr>\u003Cbr>North Carolina\u003Cbr>Department of Health and Human Services\u003Cbr>Division of Mental Health, Developmental Disabilities, and Substance Abuse Services\u003Cbr>APSM 45-2\u003Cbr>Revised March 1, 2009; Effective April 1, 2009 |  |\n| --- | --- |\n|  |  |\n\nAPSM 45-2  \nTable of Contents  \nPREFACE ..................................................................................................................................................... 1  \nREVISION OF THE SERVICE RECORDS MANUAL AS A FUNCTION OF MENTAL HEALTH REFORM ......................... 1  \nSCOPE ........................................................................................................................................................ 2  \nHOW TO USE THIS MANUAL .......................................................................................................................... 2  \nCHAPTER 1 : GENERAL RECORDS ADMINISTRATION AND REPORTING REQUIREMENTS...1-1  \nTHE VALUE OF RECORDKEEPING ...............................................................................................................1-1  \nADMINISTRATIVE REQUIREMENTS ..............................................................................................................1-1  \nPersonnel Records ............................................................................................................................. 1-2  \nIndices and Registers ......................................................................................................................... 1-2  \nRecord Retention and Disposition ...................................................................................................... 1-2  \nL ME Responsibility ......................................................................................................................................... 1-2  \nProvider Responsibility ................................................................................................................................... 1-3  \nRecords Management Requirements ............................................................................................................. 1-3  \nDHHS Records Retention and Disposition Schedule for Grants ................................................................ 1-3  \nRecords Retention and Disposition Schedule for State and Area Facilities ............................................... 1-4  \nMedicaid Records Retention Requirements ............................................................................................... 1-5  \nDestruction of Records Not Listed in a Schedule ....................................................................................... 1-5  \nTHE LME ADMINISTRATIVE RECORD FOR INDIVIDUALS SEEKING OR RECEIVING SERVICES ...........................1-5  \nTRANSFER OF RECORDS WHEN AN LME DISSOLVES OR MERGES ...............................................................1-5  \nADMINISTRATIVE STAFF SIGNATURE FILE ...................................................................................................1-6  \nDATA REPORTING REQUIREMENTS ............................................................................................................1-6  \nDocumentation and Coordination of Standardized Processes for Screening, Triage, and Referral [STR], Registration, Admission, and Discharge ................................................................................. 1-6  \nConsumer Data Warehouse [CD W] Reporting by LMEs .................................................................... 1-7  \nNorth Carolina Treatment Outcomes and Program Performance System ......................................... 1-8  \n[NC-TOPPS] ....................................................................................................................................... 1-8  \nService End-Date Reportin","cbCaintEPoWjxD4i","https://ap.wps.com/l/cbCaintEPoWjxD4i","pdf",981878,102,"English","# PREFACE\n# REVISION OF THE SERVICE RECORDS MANUAL AS A FUNCTION OF MENTAL HEALTH REFORM\n# SCOPE\n# HOW TO USE THIS MANUAL\n# CHAPTER 1 : GENERAL RECORDS ADMINISTRATION AND REPORTING REQUIREMENTS\n## THE VALUE OF RECORDKEEPING\n## ADMINISTRATIVE REQUIREMENTS\n## DATA REPORTING REQUIREMENTS\n# CHAPTER 2 : THE CLINICAL SERVICE RECORD\n## PURPOSE OF A SERVICE RECORD\n## THE IMPORTANCE OF CLINICAL DOCUMENTATION\n## TYPES OF CLINICAL SERVICE RECORDS\n## MH/DD/SA SERVICE ARRAY AND DOCUMENTATION REQUIREMENTS\n## CLOSURE OF CLINICAL SERVICE RECORDS\n## PRIVACY AND SECURITY OF SERVICE RECORDS","[{\"question\":\"Who is this manual intended for?\",\"answer\":\"It is for providers of publicly-funded MH/DD/SA services, covering CAP-MR/DD services and Local Management Entities in North Carolina.\"},{\"question\":\"What general records administration topics does Chapter 1 cover?\",\"answer\":\"Chapter 1 covers the value of recordkeeping, administrative requirements (including personnel records, indices, and retention/disposition), LME and provider responsibilities, record transfer during LME dissolution or merger, and data reporting requirements.\"},{\"question\":\"What does Chapter 2 specify about clinical service records?\",\"answer\":\"Chapter 2 defines the purpose and importance of clinical documentation, outlines types of clinical service records and the contents of a full clinical service record, and addresses closure, privacy, and security of service records.\"}]","Records Management and Documentation Manual -Providers of Publicly-Funded MH/DD/SA Services | PDF",1792754253,257]