Section 29-2354. RECORDS MANAGEMENT -- STANDARDS FOR PATIENT RECORDS MAINTENANCE AND REPORTING

 

2354.1 A substance abuse treatment facility or program shall maintain an organized record of each patient served in a secured manner.

 

2354.2 The substance abuse treatment facility or program director shall designate a staff member to be responsible for the maintenance and administration of records.

 

2354.3 The facility or program shall arrange and store records according to a uniform system approved by the Department.

 

2354.4 The facility or program shall maintain records readily accessible for use and review by authorized staff and other authorized parties.

 

2354.5 The facility or program shall organize the content of records so that information can be located easily and surveys and audits by the Department can be conducted with reasonable efficiency.

 

2354.6 The facility or program shall be linked to the systems in the Department to allow retrieval of electronic data including but not limited to outcomes of care, in a secured environment with the consent of the patient as required.

 

2354.7 The facility or program shall participate in the Department’s central registry of programs and facilities and registry of patients receiving substance abuse treatment.

 

2354.8 At a minimum, all patient records shall include:

 

(a) Documentation of the referral and initial screening interview and its findings;

 

(b) The individual’s consent to treatment;

 

(c) Orientation to the program’s services, rules, confidentiality, and patient’s rights;

 

(d) Confidentiality forms;

 

(e) Diagnostic interview and record;

 

(f) 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, the patient’s record showing any prescribed drug product by name, dosage and strength, as well as date(s) medication was administered, discontinued or changed;

 

(g) The assessment findings of the addiction counselor and community support worker;

 

(h) Individual rehabilitation plan and updates;

 

(i) Progress notes;

 

(j) Documentation of all services provided to the patient as well as activities directly related to the individual rehabilitation plan;

 

(k) Documentation of missed appointments and efforts to contact and re-engage the patient;

 

(l) Releases signed to permit the facility to obtain and/or release 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 patient, family members or significant others regarding a change in the individual’s condition and/or an unusual or unexpected occurrence in the patient’s life;

 

(p) Drug tests and incidents of drug use;

 

(q) Annual assessment and related documentation, where applicable;

 

(r) Discharge summary and aftercare plan;

 

(s) Signatures of client, counselor and clinical supervisor; and

 

(t) Outcomes of care and follow-up data concerning outcomes of care.

 

 

source

Final Rulemaking published at 47 DCR 9341 (November 24, 2000), adopting Emergency and Proposed Rulemaking published at 47 DCR 7708, 7779 (September 22, 2000).