Current through Register Vol. XLI, No. 38, September 20, 2024
20.1.
Each MAT 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 medication approved
for use in treatment of substance use disorder.
20.2. 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
18.
20.3. All patient records shall
be kept confidential in accordance with all applicable federal and state
requirements.
20.4. All patient
records shall be updated in a timely manner.
20.5. Information in the patient medical
records shall be entered by designated program staff and approved by the
program physician. Entries shall be legible and organized in an effective
manner, allowing materials to be easily retrieved.
20.6. MAT program policies and procedures
should ensure security of all records including electronic records, if
any.
20.7. Individual patient
records shall contain:
20.7.a. Identifying and
basic demographic data and the results of the screening process;
20.7.b. Documentation of program compliance
with the program's policy regarding prevention of multiple
admissions;
20.7.c. An initial
assessment report;
20.7.d. A
narrative biopsychosocial history;
20.7.e. All physical and biopsychosocial
assessments;
20.7.f. Medical
reports including results of the physical assessment; family medical history;
review of systems; laboratory reports, including results of required drug
screens; results obtained from the Controlled Substances Monitoring Program
database; and progress notes, including documentation of current dose and other
dosage data;
20.7.g. Dated case
entries of all significant contacts with patients, including a record of each
counseling session in chronological order;
20.7.h. Dates and results of case conferences
for patients;
20.7.i. The initial
and post-admission individualized treatment plan of care, and any amendments,
reviews or changes to the plans;
20.7.j. Documentation that the services
listed in the individualized treatment plan of care are available and have been
provided or offered;
20.7.k. 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 drug screens; results from the
Controlled Substances Monitoring Program database; documentation of whether the
patient was offered or accepted a detoxification treatment plan option; and any
other significant change in treatment, both positive and negative;
20.7.l. Coordination of care agreements
signed by the patient, program physician and primary counselor;
20.7.m. Documentation that the MAT program
made a good faith effort to review whether the patient is enrolled in any other
MAT program;
20.7.n. A record of
correspondence with the patient, family members and other individuals and a
record of each referral for services and its results;
20.7.o. A record of correspondence with other
health care providers of the patient;
20.7.p. 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 was discussed with the patient;
20.7.q. Consent forms, releases of
information, prescription documentation, travel, employment and take-home
documentation; and
20.7.r. A
closing summary, including reasons for discharge and any referral. In the case
of death, the cause of death, if known, shall be documented.
20.8. Documentation of Patient
Contact.
20.8.a. The primary counselor or
medical staff is responsible for documentation of significant contact with each
patient, which shall be filed in the patient record and include a description
of:
20.8.a.1. The reason for or nature of the
contact;
20.8.a.2. The patient's
current condition;
20.8.a.3.
Significant events occurring since prior contact;
20.8.a.4. The assessment of patient status;
and
20.8.a.5. A plan for action or
further treatment.
20.8.b. Each entry shall be completed by the
next business day following the contact and shall be clearly dated and
initialed or signed by the staff person involved.
20.9. A MAT program that closes or
discontinues MAT program services shall arrange for continued management of all
patient records as follows:
20.9.a. Within 10
days of closure, the owner of the MAT program shall notify the Secretary, or
his or her designee, in writing of the address where records will be stored and
specify the individual who will be managing records and that individual's
contact information.
20.9.b. The
owner of the MAT program shall arrange for the storage of each record through
one or more of the following measures:
20.9.b.1. The owner of the MAT program shall
continue to manage the records and give written assurance to the Secretary or
his or her designee that it will respond to authorized requests for copies of
patient records within 10 working days;
20.9.b.2. The owner of the MAT program shall
transfer records of patients who have given written consent to another MAT
program within five days of the request; or
20.9.b.3. The owner of the MAT program will
enter into an agreement with another MAT program to store and manage the
patient records.
