New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS
Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS
Section 8.370.12.40 - ADDITIONAL REQUIREMENTS FOR PSYCHIATRIC HOSPITALS
Universal Citation: 8 NM Admin Code 8.370.12.40
Current through Register Vol. 35, No. 18, September 24, 2024
A. Additional medical record requirements: The medical records maintained by a psychiatric hospital shall document the degree and intensity of the treatment provided to individuals who are furnished services by the facility. A patient's medical record shall contain:
(1) identification
data, including the patient's legal status;
(2) the reason for treatment or chief
complaint in the words of the patient, when possible, as well as observations
or concerns expressed by others;
(3) the psychiatric evaluation, including
medical history containing a record of mental status and noting the onset of
illness, the circumstances leading to admission, attitudes, behavior, estimate
of intellectual functions, memory functioning, orientation and an inventory of
the patient's personality assets recorded in descriptive fashion;
(4) social services records, including
reports of interviews with patients, family members and others and an
assessment of home plans, family attitudes and community resource contacts as
well as social history;
(5) a
comprehensive treatment plan based on an inventory of the patient's strengths
and disabilities, which shall include:
(a) at
least one diagnosis;
(b) short-term
and long-range goals;
(c) the
specific treatment modalities used; and
(d) the responsibilities of each member of
the treatment team.
(6)
staff shall plan, implement and revise, as indicated, a written, individualized
treatment program for each patient based on:
(a) the degree of psychological impairment
and appropriate measures to be taken to relieve treatable distress and to
compensate for nonreversible impairments;
(b) the patient's capacity for social
interaction;
(c) environmental and
physical limitations such as seclusion room or restraints, required to
safeguard the individual's health and safety with an appropriate plan of care;
and
(d) the individual's potential
for discharge and successful care management on an outpatient basis.
(7) the documentation of all
active therapeutic efforts and interventions;
(8) progress notes related to treatment needs
and the treatment plan are reviewed, revised and recorded at least weekly as
the status of the patient requires by the physician, nurse, social worker and
staff from other appropriate disciplines involved in active treatment
modalities, as indicated by the patient's condition; and
(9) discharge information, including:
(a) recommendations from appropriate services
concerning follow-up care; and
(b)
at least one diagnosis.
B. Additional treatment plan and staffing requirements:
(1) The hospital
shall have enough staff with appropriate qualifications to carry out an active
plan of psychiatric treatment for individuals who are furnished services in the
facility.
(2) The treatment of
psychiatric inpatients shall be under the supervision of a qualified physician
who shall provide for taking an active role in an intensive treatment
program.
(3) If nonpsychiatric
medical and surgical diagnostic and treatment services are not available within
the facility, qualified consultants or attending physicians shall be
immediately available if a patient should need this attention, or an adequate
arrangement shall be in place for immediate transfer of the patient to an
acute-care hospital.
(4) Nursing
services shall be under the supervision of a professional registered nurse
qualified to care for psychiatric patients and, by demonstrated competence, to
participate in interdisciplinary formulation of individual treatment plans, to
give skilled nursing care and therapy, and to direct, supervise and educate
others who assist in implementing the nursing component of each patient's
treatment plan.
(5) Professional
registered nurses and other nursing personnel shall participate in
inter-disciplinary meetings affecting the planning and implementation of
treatment plans for patients, including diagnostic conferences, treatment
planning sessions and meetings held to consider alternative facilities and
community resources.
(6)
Psychological services shall be under the supervision of a psychologist
licensed under the Professional Psychologists Act, Section 61-91 through
61-9-18 NMSA 1978.
There shall be enough psychologists, consultants and support personnel qualified to carry out their duties to:
(a) assist in essential diagnostic
formulations;
(b) participate in
program development and evaluation;
(c) participate in therapeutic interventions
and in interdisciplinary conferences and meetings held to establish diagnoses,
goals and treatment programs.
(7) The number of social work staff qualified
to carry out their duties shall be adequate for the hospital to meet the
specific needs of individuals patients and their families and develop community
resources and for consultation to other staff and community agencies. The
social work staff shall:
(a) provide
psychosocial data for diagnosis and treatment planning;
(b) provide direct therapeutic services;
and
(c) participate in
interdisciplinary conferences and meetings on diagnostic formulation and
treatment planning, including identification and use of alternative facilities
and community resources.
(8) The number of qualified therapists and
therapist assistants shall be sufficient to provide needed therapeutic
activities, including, when appropriate, occupational, recreational, and
physical therapy, to ensure that appropriate treatment is provided to each
patient.
(9) The total number of
rehabilitation personnel, including consultants, shall be sufficient to permit
appropriate representation and participation in inter-disciplinary conferences
and meetings, including diagnostic conferences, which affect the planning and
implementation of activity and rehabilitation programs.
Disclaimer: These regulations may not be the most recent version. New Mexico 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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