Current through Register Vol. XLI, No. 38, September 20, 2024
18.1. Each
OBMAT 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 medications approved for
use in treatment of substance use disorder.
18.2. 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.
18.3. All patient records shall
be kept confidential in accordance with all applicable federal and state
requirements.
18.4. OBMAT program
policies and procedures should ensure security of all records including
electronic records, if any.
18.5.
Individual patient records may include, but are not limited to:
18.5.1. Identifying and basic demographic
data and the results of the screening process;
18.5.2. Documentation of program compliance
with the program's policy regarding prevention of multiple admissions to any
medication-assisted treatment programs;
18.5.3. All physical and biopsychosocial
assessments during the course of treatment;
18.5.4. Medical reports including results of
the physical assessment; family medical history; review of systems; laboratory
reports, including results of required toxicology screens; results obtained
from the Controlled Substances Monitoring Program (CSMP) database; and progress
notes, including documentation of current dose and other dosage data;
18.5.5. Dated case entries of all significant
contacts with patients;
18.5.6. The
individualized plans of care or treatment strategies, and any amendments,
reviews, or changes to the plans;
18.5.7. Coordination of care agreements
signed by the patient, program physician and primary counselor;
18.5.8. Documentation from the Controlled
Substance Monitoring Program or an out-of-state equivalent that the OBMAT
program made a good faith effort to review whether the patient is enrolled in
any other OBMAT program;
18.5.9. A
record of correspondence with the patient, family members, and other
individuals and a record of each referral for services and its
results;
18.5.10. A record of
correspondence with other health care providers of the patient;
18.5.11. Consent forms, releases of
information, prescription documentation, travel, and employment; and
18.5.12. A closing summary, including reasons
for discharge and any referral. In the case of death, the cause of death, if
known, shall be documented.
18.6. Documentation of Patient Contact.
The primary counselor or medical staff, or both is
responsible for documentation of significant contact with each patient, which
shall be filed in the patient record and include a description of:
18.6.1. The reason for or nature of the
contact;
18.6.2. The patient's
current condition;
18.6.3.
Significant events occurring since prior contact;
18.6.4. The assessment of patient status;
and
18.6.5. A plan for action or
further treatment.
