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NC Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

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Records Management

DRAFT RM&DM – 3rd Edition For Review and Comment

The Records Management and Documentation Manual [RM&DM] has been revised since its last update in 2009 and is earmarked for implementation on July 1, 2015. Following are links to an editable copy of the draft manual and the appendix. These documents are in tracked changes to facilitate providing comments and feedback.

Please send your comments to by May 27, 2015.

The revisions contained in this draft reflect updated information, input, and edits from a number of people who have sifted through the detail in order to bring the manual up to date and current with our service delivery system. It is important to us that your membership is given the opportunity to provide feedback before its finalization and implementation.

The current revisions reflect many of the recent policy changes, as well as various clarifications throughout the manual in response to questions or comments from the field. Some of the revisions to this edition of the RM&DM include the following:

  • An expanded section on the Consumer Data Warehouse [CDW] reporting requirements;
  • The elimination of the Introductory Person-Centered Plan [PCP] and updating the PCP guidance;
  • The basic requirements for a service plan when a Person-Centered Plan is not required;
  • Additional documentation guidance related to discharge planning;
  • Updated information and guidance on service notes;
  • Additional information about signatures;
  • Removal of requirements specific to CAP-MR/DD, now NC Innovations;
  • Updates for respite, Opioid Treatment, Psychosocial Rehabilitation [PSR], and other specific services;
  • Updating language, for example, substance use instead of substance abuse, where applicable;
  • A renaming and re-ordering of some chapters; and
  • Updating the appendix.

Managing the life cycle of records is the responsibility of all DMH/DD/SAS, LME, and provider agency staff. Records management refers to: “…the application of efficient and economical management methods [for] the creation, utilization, maintenance, retention, preservation, and disposal of official records…” (GS §132-8.1). DMH/DD/SAS, LMEs and providers are required to demonstrate compliance to the provisions of Chapter 121 Section 5 and Chapter 132 of the General Statutes which govern the retention and disposition of public records.

Complying with record retention and record management is the responsibility of both administrators and providers.

Links to Resources for Records Management

Special reminders about record retention and disposition:

  • The schedules only apply to original documents -- not copies.
  • The schedules apply to all aspects of conducting state business -- administrative, financial, and management records -- not just to consumer records.
  • When a document falls under two different retention schedules, the stricter schedule applies. 
  • The funding source often determines how long a record must be retained.
  • Records associated with federally funded grant programs shall be retained for at least ten years and for three years after the program has ended, provided the organization had a clean audit. [Note: DMA-PI and the Medicaid Investigations Unit can go back up to ten years to investigate or to request recoupment of funds. ]

Executive Order 18: E-mail Retention and Archiving Policy

Governor Perdue signed Executive Order 18, which rescinded Executive Order 150, on July 7, 2009. This order identifies the responsibilities of state employees and state agencies concerning the retention and disposition of e-mail messages. Some of the provisions of this order include:

  • A statement should be placed in the signature section of all e-mail to notify recipients that any e-mail sent to and from a State e-mail account is subject to the NC Public Records Law and may be disclosed to third parties.
  • Any e-mail messages sent or received in connection with the transaction of State business shall not be permanently deleted for at least 24 hours to allow ITS to back-up e-mail.
  • Any e-mail that is retained or deleted shall be done so according to the DMH retention and disposition schedules (APSM 10-3 and APSM 10-4) and the General Schedule for State Agencies.
  • Each employee is required to take the mandatory online training "Managing Your Inbox: E-Mail as a Public Record,"  which was developed by the Department of Cultural Resources.

Presentation: "Record Retention: An Overview of What You Should Know"

Local Management Entities and Chief of Medical Records Roster (8/2014)

Records management information for those we serve.

If there are records management or records retention questions, please contact Ready NC Connect NC