New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES
Part 10 - OPIOID TREATMENT PROGRAMS
Section 8.321.10.28 - PATIENT RECORDS
Universal Citation: 8 NM Admin Code 8.321.10.28
Current through Register Vol. 35, No. 18, September 24, 2024
A. The OTP program shall establish and maintain a recordkeeping system that is adequate to document and monitor patient care. The system shall comply with all federal and state requirements relevant to OTPs and to confidentiality of patient records.
B. Each patient record shall include:
(1) the results of the
physical examination;
(2) the
results of all assessments;
(3) the
treatment plan and all updates or revisions;
(4) the results of laboratory tests and a
description of any action taken based upon the results;
(5) documentation of the patient's current
dose and dosage history;
(6)
documentation of counseling provided to the patient;
(7) dates and results of meetings or
conferences regarding the patient's treatment;
(8) documentation of the process used and
factors considered in making decisions that impact a patient's treatment, such
as whether to allow take-home medication and the frequency of laboratory drug
detection tests; and
(9)
documentation of the agency's efforts to learn of multiple opioid treatment
program enrollment;
(10)
documentation that the patient has received and understood information
regarding the harmful effects of diversion of opioid treatment
medication.
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