Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.106 - HEALTH CARE FACILITIES
Subchapter 37.106.14 - Minimum Standards for Chemical Dependency Facilities
Rule 37.106.1454 - CLIENT RECORD CONTENT REQUIREMENTS

Universal Citation: MT Admin Rules 37.106.1454

Current through Register Vol. 6, March 22, 2024

(1) The substance use disorder residential facility (SUDF) must develop and implement procedures to ensure each client record is available on-site and includes:

(a) demographic information;

(b) a substance related disorder diagnosis and supporting documentation for diagnosis;

(c) biopsychosocial assessment including diagnosis showing the rationale for admission;

(d) signed documentation the client was informed of federal confidentiality requirements and received a copy of the client notice as required in ARM 37.106.1416;

(e) signed documentation the client received orientation to the SUDF's treatment services, infectious disease information, and disaster plan described in ARM 37.106.322;

(f) a voluntary consent to treatment signed and dated by the client or legal guardian;

(g) individualized treatment plan and treatment plan reviews;

(h) progress notes;

(i) clinical notes;

(j) continuing care plan;

(k) medication records, if applicable;

(l) laboratory reports, if applicable;

(m) authorizations for release of information, as needed;

(n) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and

(o) documentation pertaining to client receipt of grievance policies and procedures.

(p) documentation of any client-filed written grievances and resolution;

(q) documentation the client received a copy of the client rights policy and the client's signature indicating he/she received the policy; and

(r) documentation of school educational courses attended or provided.

AUTH: 50-5-103, 53-24-208, MCA; IMP: 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

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