Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 3
Subtitle 21 - MENTAL HYGIENE REGULATIONS
Chapter 10.21.17 - Community Mental Health Programs-Definitions and Administrative Requirements
Section 10.21.17.08 - Records
Universal Citation: MD Code Reg 10.21.17.08
Current through Register Vol. 51, No. 19, September 20, 2024
A. General Requirements.
(1) The program shall, either
manually or electronically:
(a) Establish a
record for an individual who receives services from the program; and
(b) Ensure that entries in the record are
dated, signed, and include the signer's degree or license, or if the signer has
no degree or license, the signer's staff position.
(2) The program director shall ensure that
individuals' program records are:
(a)
Maintained in a manner that is consistent with the medical records
confidentiality and disclosure requirements of:
(i) Maryland Confidentiality of Medical
Records Act, Health-General Article, Title 4, Subtitle 3, Annotated Code of
Maryland; and
(ii) Relevant federal
statutes and regulations, including the Health Insurance Portability Act,
42 U.S.C. § 1320D et seq., and implementing regulations
at 45 CFR Parts 160 and 164;
(b) Located so that the records are
convenient and available to designated staff;
(c) Managed by a designated staff member who
is responsible for appropriate records control, including storage, security,
and indexing of records; and
(d)
Subject to the requirements of confidentiality laws and regulations, are made
available to the Department, the Administration's ASO, the CSA, and the Office
of Inspector General, as necessary to carry out required activities.
B. Contents of Record. When an individual is enrolled in a program, the program shall maintain a record of, at a minimum:
(1) Identifying
information, including but not limited to:
(a)
Name, sex, race, marital status, and date of birth of the individual;
(b) Address and telephone number;
and
(c) As permitted by law, Social
Security number;
(2)
Name, address, and telephone number of the individual to be contacted in case
of emergency;
(3) Dates of
enrollment and initial service;
(4)
Source of referral;
(5) If the
individual has been referred upon discharge from an inpatient facility:
(a) A copy of the aftercare plan and
discharge summary; or
(b)
Documentation that the program has requested a copy of the aftercare plan and
discharge summary;
(6)
If an individual has been court-ordered to receive evaluation or treatment, a
copy of the court order;
(7)
Documentation of verification of the individual's financial information, or, if
the individual is a minor, the minor's parent's financial information necessary
to implement the Department's requirements on the setting of charges and
collection of fees;
(8) Presenting
problem and history of the presenting problem, including, if known,
precipitating factors and, if any, history of substance abuse;
(9) Either, if indicated and relevant:
(a) Copies of reports and recommendations of
prior treatment, tests, and evaluations, including, when received, a report or
summary of current physical examination; or
(b) Documentation that the program has
requested a copy of any reports and recommendations of prior treatment, tests,
and evaluations;
(10)
For a minor who is enrolled in a program, copies of legal documents related to
the minor's status, including but not limited to:
(a) Court orders; and
(b) Custody agreements;
(11) For a minor who is enrolled in a
program, an emergency contact form, which is up-to-date and which includes:
(a) The name, address, and daytime telephone
number of the primary caretaker;
(b) The name, address, and telephone number
of the primary care provider; and
(c) If available, the names, addresses, and
daytime telephone numbers of at least two individuals to be contacted in case
of emergency when the primary caretaker cannot be reached;
(12) The consent forms, signed by the
individual or the individual's parent or guardian, as appropriate, for:
(a) Participation in the program and
activities provided by the program; and
(b) Releasing information to or requesting
information from other agencies, including the CSA, and health care
providers;
(13)
Documentation of the clinical information as required in the chapter under this
subtitle for specific program requirements;
(14) If applicable, names and either
addresses or telephone numbers of the individual's psychiatrist, therapist,
case manager, primary care provider, managed care organization, and insurance
carrier; and
(15) The individual's
discharge plan and summary.
Disclaimer: These regulations may not be the most recent version. Maryland may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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