Current through Register Vol. XLI, No. 38, September 20, 2024
25.1.
Each opioid treatment program shall establish and maintain a recordkeeping
system that is adequate to document and monitor patient care. The system shall
comply with all federal and state reporting requirements relevant to opioid
drugs approved for use in treatment of opioid addiction.
25.2. All patient records shall be maintained
for a minimum of five years from the time that the documented treatment is
provided. In the event a patient is a juvenile, the records shall be kept for a
minimum of five years from the time the patient reaches the age of eighteen
years.
25.3. All patient records
shall be kept confidential in accordance with all applicable federal and state
requirements.
25.4. All patient
records shall be updated in a timely manner.
25.5. Information in the patient medical
records shall be entered only by physicians and other licensed health
professionals. Entries shall be legible and organized in an effective manner,
allowing materials to be easily retrieved.
25.6. Opioid treatment program procedures
should ensure security of all records including electronic records, if
any.
25.7. Individual patient
records shall contain:
25.7.a. Identifying and
basic demographic data and the results of the screening process;
25.7.b. Documentation of program compliance
with the program's policy regarding prevention of multiple
admissions;
25.7.c. An initial
assessment report;
25.7.d. A
narrative bio-psychosocial history completed within thirty days of the
patient's admission;
25.7.e.
Medical reports including results of the physical examination; past and family
medical history; review of systems; laboratory reports, including results of
required toxicology screens; results obtained from the Controlled Substances
Monitoring Program database; and progress notes, including documentation of
current dose and other dosage data;
25.7.f. Dated case entries of all significant
contacts with patients, including a record of each counseling session in
chronological order;
25.7.g. Dates
and results of case conferences for patients;
25.7.h. The initial and post-admission
individualized treatment plans of care, and any amendments, reviews or changes
to the plans;
25.7.i. Documentation
that the services listed in the individualized treatment plan of care are
available and have been provided or offered;
25.7.j. A written report of the treatment
process; factors considered in decisions impacting patient treatment (e.g.,
take-home medication privileges, changes in counseling sessions, changes in
frequency of toxicology screens; results from the Controlled Substances
Monitoring Program database); documentation of whether the patient was offered
or accepted a detoxification treatment plan option; or any other significant
change in treatment, both positive and negative;
25.7.k. Documentation that the opioid
treatment program made a good faith effort to review whether the patient is
enrolled in any other opioid treatment program;
25.7.l. A record of correspondence with the
patient, family members and other individuals and a record of each referral for
services and its results;
25.7.m.
Documentation that the patient was provided with a copy of the program's rules
and regulations; a copy of the patient's rights and responsibilities; a copy of
the detoxification treatment plan option, if applicable; a copy of the
patient's individualized treatment plan of care; a copy of the patient's goals;
and documentation that each of these items were discussed with the
patient;
25.7.n. Consent forms,
releases of information, prescription documentation, travel, employment and
"take-home" documentation, etc.; and
25.7.o. A closing summary, including reasons
for discharge and any referral. In the case of death, the cause of death shall
be documented.
