New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 371 - DEVELOPMENTAL DISABILITIES
Part 2 - REQUIREMENTS FOR INTERMEDIATE CARE FACILITIES FOR THE MENTALLY RETARDED
Section 8.371.2.25 - CLIENT RECORDS

Universal Citation: 8 NM Admin Code 8.371.2.25

Current through Register Vol. 35, No. 18, September 24, 2024

The facility must develop and maintain a record keeping system that includes a separate record for each client which documents the client's health care, active treatment, social information, and protection of the client's rights. As a minimum the client's record must contain:

A. Personal information:

(1) full name;

(2) date of birth;

(3) social security number;

(4) height;

(5) weight;

(6) color of hair;

(7) color of eyes;

(8) identifying marks and recent photograph;

(9) full name of parents and their dates of birth;

(10) language(s) spoken and understood and language used in the natural home;

(11) information relevant to religious preference;

(12) legal documentation relevant to commitment or guardianship status;

(13) name, address, and telephone number of next-of-kin, other person or agency to contact in case of an emergency.

B. Medical information:

(1) reports of previous histories, evaluations or observations;

(2) age at onset of disability;

(3) name, address and telephone number of physician or health facility providing medical care;

(4) medication history, including present medication dosage and schedule;

(5) reports of all treatments, etc.

C. Individual habilitation plan: Each client must have an individual habilitation plan which specifies goals and objectives.

D. Admission agreement.

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.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.