New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES
Part 11 - CRISIS TRIAGE CENTERS
Section 8.321.11.28 - CLIENT CLINICAL RECORD
Current through Register Vol. 35, No. 18, September 24, 2024
The client clinical records maintained by a crisis triage center in a paper-based or electronic system shall document the degree and intensity of the treatment provided to clients who are furnished services by the CTC. A client's clinical record shall contain at a minimum:
A. the client's name and address;
B. name, address, and telephone number of agent, or representatives;
C. the source of referral and relevant referral information;
D. all reports from client assessment (see program services assessment);
E. the signed and dated informed consent for treatment including all medications and transfers;
F. all additional medical and clinical documentation;
G. the original crisis stabilization plan and all revisions;
H. documentation of all treatment;
I. laboratory and radiology results, if applicable;
J. documentation of physical restraint observations, if utilized;
K. a record of all contacts with medical and other services;
L. a record of medical treatment and administration of medication, if administered;
M. an original or original copy of all physician medication and treatment orders signed by the physician;
N. signed consent for the release of information, if information is released;
O. discharge plan.
