Current through Bulletin 2024-06, March 15, 2024
(1) Section
R432-100-35, Medical Records,
applies to a substance use disorder specialty hospital.
(2) The licensee shall ensure the content of
the patient record contains:
(a) progress
notes, including description and date of service, with a summary of client
progress, signed by the therapist or service provider; and
(b) a discharge summary, including final
evaluation of treatment and goals attained and signed by the
therapist.
(3) The
licensee shall ensure:
(a) a written
individual treatment plan is initiated for each patient upon admission and
completed within seven working days following admission;
(b) the individual treatment plan is part of
the patient record and signed by the responsible party for the patient's
care;
(c) patient care is
administered according to the individual treatment plan;
(d) individual treatment plans are reviewed
on a weekly basis for the first three months, and at intervals determined by
the treatment team, but not to exceed every other month;
(e) the written individual treatment plan is
based on a comprehensive functional medical, psycho-social, substance use, and
treatment history assessment of each patient;
(f) when appropriate, the patient and family
is invited to participate in the development and review of the individual
treatment plan and any patient and family participation is documented;
and
(g) the individual treatment
plan is available to any personnel who provide care for the
patient.
(4) The Utah
State Hospital is exempt from the time frames listed in Subsection
R432-102-14(3)(a)
for initiating and reviewing the individual treatment plan and shall initiate
an individual treatment plan for each patient admitted within 14 days and
review the plan on a monthly basis.
(5) The licensee shall ensure the
confidentiality of the records of substance use disorder patients are
maintained according to The Code of Federal Regulations, Title 42, Part 2,
Confidentiality of Substance Use Disorder Patient Records.
