Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.106 - HEALTH CARE FACILITIES
Subchapter 37.106.18 - Licensure of Specialty Mental Health Facilities
Rule 37.106.1805 - SPECIALTY MENTAL HEALTH FACILITY: MEDICAL RECORDS
Universal Citation: MT Admin Rules 37.106.1805
Current through Register Vol. 6, March 22, 2024
(1) A specialty mental health facility must maintain a medical records system in accordance with written policies and procedures, as well as meet the following standards:
(a) Employ adequate personnel to ensure
prompt and systematic completion, filing, and retrieval of records.
(b) Create and maintain a record for each
person receiving specialty mental health care services from the facility that
includes, if applicable:
(i) identification
and social data;
(ii) admitting
diagnosis;
(iii) pertinent medical
history;
(iv) properly executed
consent forms;
(v) reports of
physical examinations, diagnostic and laboratory test results, and consultation
findings;
(vi) all physician's
orders, nurses' notes, and reports of treatments and medications;
(vii) final diagnosis;
(viii) discharge summary; and
(ix) any other pertinent information
necessary to monitor the patient's prognosis.
(c) Include in each record the signatures of
the physician or other health care professional authoring the record
entries.
(d) Complete records of a
discharged patient within 30 days after the discharge date and include, in
addition to the information cited in (b) above, a recapitulation of the
patient's period of treatment, a recommendation of the appropriate follow up or
aftercare services for the patient, and a brief summary of the patient's
medical and mental condition on discharge.
(e) Have written policies and procedures
ensuring the confidentiality of patient records, and safeguards against loss,
destruction or unauthorized use, in accordance with applicable state and
federal law and including policies and procedures which:
(i) govern the use and removal of records
from the record storage area;
(ii)
specify the conditions under which information may be released and by
whom;
(iii) specify when the
patient's consent is required for release of information, in accordance with
Title 50, chapter 16, part 5, MCA, the Uniform Health Care Information
Act.
(f) In addition to
the above, adhere to the provisions of ARM
37.106.314.
(2) The department hereby adopts and incorporates by reference ARM 37.106.314, which contains medical records requirements for types of health care facilities other than hospitals. Copies may be obtained from the Department of Public Health and Human Services, Quality Assurance Division, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953.
Sec. 50-5-103, MCA; IMP, Sec. 50-5-103, MCA;
Disclaimer: These regulations may not be the most recent version. Montana 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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