South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-93 - Standards for Licensing Facilities for Chemically Dependent or Addicted Persons
Sec2 61-93.700 - PATIENT RECORDS
Section 61-93.700.701 - Content (II)

Universal Citation: SC Code Regs 61-93.700.701

Current through Register Vol. 48, No. 9, September 27, 2024

A. The Facility shall initiate and maintain a Patient record for every individual screened, assessed and/or treated. The record shall contain sufficient information to identify the Patient and the agency and/or person responsible for each Patient, support the diagnosis, justify the treatment, and describe the response and/or reaction to treatment. The record contents shall also include the provisions for release of information, Patient rights, consent for treatment (approval by parent and/or guardian of Patient), Medications prescribed and administered, and diet (Residential Facilities only), documentation of the course and results, and promote continuity of treatment among treatment providers, consistent with acceptable standards of practice. In Facilities providing services for Parents with children, the name and age of each child shall be maintained in the Facility. All entries shall be written legibly in ink, typed, or electronic media, and signed and dated or documented in the electronic medical record.

B. If the Facility permits any portion of a Patient's record to be generated by electronic or optical means, there shall be policies and procedures to prohibit the use or authentication by unauthorized users.

C. Specific entries and documentation shall include at a minimum:

1. Consultations by Physicians or other Authorized Healthcare Providers;

2. Signed and dated orders and recommendations for all Medication, care, services, and diet (Residential Facilities only) from Physicians or other Authorized Healthcare Providers, which shall be completed prior to, or at the time of admission, and subsequently, as warranted; (I)

3. Intake screening and initial physical assessment completed by the nurse or Counselor;

4. A signed and dated original consent for treatment; (I)

5. The report of the mental status examination and other mental health assessments as defined in Section 101.G. as appropriate;

6. Notes of counseling sessions and any other changes in the Patient's mental and physical condition; and

7. Medication management and administration, and treatment records.

8. Discharge summary, completed within a time-period as determined by the Facility, but no later than three (3) business days, and shall include at minimum:
a. Time and circumstances of Discharge or transfer, including condition at Discharge or transfer, or death; and

b. The recommendations and arrangements for further treatments, including Aftercare.

D. Electronic signatures may be used in the Patient record if they are in accordance with applicable laws and regulations, and require a signature. Electronic authorization shall be limited to a unique identifier (confidential code) used only by the individual making the entry to preclude the improper or unauthorized use of any electronic signature

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