Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.106 - HEALTH CARE FACILITIES
Subchapter 37.106.19 - Minimum Standards for Mental Health Centers
Rule 37.106.1983 - OUTPATIENT CRISIS RESPONSE FACILITY: CLINICAL RECORDS
Universal Citation: MT Admin Rules 37.106.1983
Current through Register Vol. 6, March 22, 2024
(1) Each crisis response facility shall collect assessment data and maintain clinical records on all clients who receive services.
(2) Each facility must ensure the confidentiality of clinical records in accordance with the Health Information Portability and Accountability Act (HIPAA).
(3) At a minimum, the clinical record must include:
(a) a clinical intake
assessment;
(b) additional
assessments or evaluations, if clinically indicated;
(c) a copy of the client's individualized
crisis treatment plan and all modifications to the crisis treatment
plan;
(d) progress notes which
indicate whether or not the stated treatment plan has been implemented, and the
degree to which the client is progressing, or failing to progress, toward
stated treatment objectives;
(e)
medication orders from the prescribing physician and documentation of the
administration of all medications;
(f) signed orders by a licensed mental health
professional for any restrictions of rights; and, privileges accorded clients
of the crisis response facility including the reasons for the restriction;
and
(g) a discharge summary which
must be completed within one week of the date of discharge.
50-5-103, MCA; IMP, 50-5-103, MCA;
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