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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 22. HEALTH |
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SubTilte 22-A. MENTAL HEALTH |
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Chapter 22-A63. CERTIFICATION STANDARDS FOR SUBSTANCE USE DISORDER TREATMENT AND RECOVERY PROVIDERS |
Section 22-A6322. CLIENT RECORD CONTENTS
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6322 CLIENT RECORD CONTENTS
6322.1 At a minimum, all client records shall include:
(a)Documentation of the referral and initial screening interview and its findings;
(b)The individual's consent to treatment;
(c)The Client’s Rights Statement;
(d)Documentation that the client received:
(1) An orientation to the program's services, rules, confidentiality, and client's rights;
(2) Notice of privacy practices;
(e)Confidentiality forms and releases signed to permit the facility to obtain and/or release information;
(f)Diagnostic interview and assessment record, including any Department-approved screening and assessment tools;
(g)Evaluation of medical needs and, as applicable, medication intake sheets and special diets which shall include:
(1) Documentation of physician's orders for medication and treatment, change of orders, and/or special treatment evaluation; and
(2) For drugs prescribed following admissions, any prescribed drug product by name, dosage, and strength, as well as date(s) medication was administered, discontinued, or changed;
(h)Assessments and individual treatment plans pursuant to the level of care and the client’s needs, including recovery plans, if applicable;
(i)Encounter notes, which provide sufficient written documentation to support each therapy, service, activity, or session for which billing is made that, at a minimum, consists of:
(1) The specific service type rendered;
(2) Dated and authenticated entries with their authors identified, that include the duration, and actual time (beginning and ending as well as a.m. or p.m.), during which the services were rendered;
(3) Name, title, and credentials (if applicable) of the person providing the services;
(4) The setting in which the services were rendered;
(5) Confirmation that the services delivered are contained in the client’s treatment or recovery plan and are identified in the encounter note; and
(6) A description of each encounter or intervention provided to the client, which is sufficient to document that the service was provided in accordance with this chapter;
(7) The client’s response to the intervention; and
(8) Provider’s observations.
(j)Documentation of all services provided to the client as well as activities directly related to the individual treatment or recovery plan that are not included in encounter notes;
(k) Documentation of missed appointments and efforts to contact and re-engage the client;
(l) Emergency contact information of individuals to contact in case of a client emergency with appropriate consent to share information;
(m) Documentation of all referrals to other agencies and the outcome of such referrals;
(n) Documentation establishing all attempts to acquire necessary and relevant information from other sources;
(o) Pertinent information reported by the client, family members, or significant others regarding a change in the individual's condition and/or an unusual or unexpected occurrence in the client's life;
(p) Drug test results and incidents of drug use;
(q) Discharge summary and aftercare plan;
(r) Outcomes of care and follow-up data concerning outcomes of care;
(s) Documentation of correspondence with other medical, community providers, social service, and criminal justice entities as it pertains to a client’s treatment and/or recovery; and
(t) Documentation of a client’s representative payee or legal guardian, as applicable.