Section 29-4905. TREATMENT RECORDS

 

4905.1All phases of the client's treatment program and related information shall be reflected in the record.

 

4905.2The treatment record shall include, but not be limited to, the following:

 

(a)Complete identification data, including Medicaid number and other third party payor information, if applicable.

 

(b)Medical history, initial and subsequent assessments and evaluations, and initial and subsequent Plans of Care,

 

(c)Brief progress notes, signed and dated: and

 

(d)Summaries of significant face-to face contact by each health care professional with the client, that are signed and dated by the health care professional, to readily identify and support Medicaid billing.

 

4905.3Each Provider shall document each service provided to the client in the treatment record, at the time of the occurrence and include at a minimum the following information:

 

(a)Date of service;

 

(b)Name and location of the service provider; and

 

(c)Description of the service.

 

4905.4Each Provider shall maintain and secure client treatment records.

 

4905.5Each Provider shall establish procedures for safeguarding client information pursuant to 42 CFR 431.305, and shall ensure that, except as otherwise provided by federal or District law or rules, the use or disclosure of client information shall be restricted to purposes related to the administration of the Medicaid Program, as set forth in 42 CFR 431.302.

 

source

Emergency Rulemaking published at 48 DCR 8872 (September 21, 2001) [EXPIRED]; as amended by Final Rulemaking published at 49 DCR 247 (January 11, 2002).