Section 29-806. MEDICAL RECORDS

 

806.1All phases of the patient's program, and related information, shall be entered in the record.

 

806.2The medical records shall include, but are not limited to, the following:

 

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

 

(b)Medical history, initial psychiatric and social evaluations, and histories, and, if appropriate, social service and nursing care plans for meeting current and future personal, financial, social, and nursing needs of the patient;

 

(c)Physician's medication orders and medications given by the appropriate nursing personnel, noted and signed;

 

(d)All medical treatment received during treatment and appropriate progress notes related to it. Patients on drugs should have, where indicated, routing blood or other examinations to detect irregularities, duly recorded;

 

(e)Periodic interdisciplinary reviews, at intervals not to exceed three (3) months, regarding the care, treatment, and progress of the patient to ensure that all appropriate measures are taken for the patient's improvement and that continued treatment is necessary. These reviews shall include a substantive evaluation of the treatment plan. The patient's continuing need for treatment shall be clearly documented;

 

(f)Brief progress notes, to be written by the mental health professional responsible for carrying out the treatment plan and entered at least monthly;

 

(g)Summary of significant, face-to-face contact by mental health professionals with the patient sufficient to readily identify and support Medicaid billing; and

 

(h)Each record entry shall show the signature, discipline, and date entered.

 

source

Final Rulemaking adopted at 29 DCR 264 (January 15, 1982).