D.C. Mun. Regs. tit. 22, r. 22-A3008

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-A3008 - MEDICAL RECORDS

3008.1

All phases of the consumer's treatment and related information shall be entered in the consumer's medical record.

3008.2

The FSMHC shall utilize an EHR system certified by the Department of Health and Human Services Office of the National Coordinator for Health Information Technology to document all phases of the individual's treatment and care.

3008.3

The medical records shall include, but are not limited to, the following:

(a) Complete identification data, including Medicaid number and other third-party payer information;

(b) Medical history, initial psychiatric evaluation, psychosocial assessment, and histories, and, if appropriate, social service and nursing care plans for meeting current and future personal, financial, social, and nursing needs of the consumer;

(c) A record of a screening for the presence of a co-occurring substance use disorder at intake and upon any treatment plan revision;

(d) Individual plan of care, completed in accordance with §§ 3009 of this chapter;

(e) Psychiatrist's, Physician's Assistant, or APRN's medication orders that shall include:

(1) The name of the medications(s);

(2) The dosage, route and frequency of administration;

(3) The quantity given;

(4) The number of refills; and

(5) The signature of the authorized staff rendering the service.

(f) Documentation of all behavioral health-related medical treatment received during treatment at the FSMHC and appropriate encounter notes related to it. Consumers on medications should have, where indicated, routine blood or other examinations to detect irregularities duly recorded;

(g) Encounter notes, to include sufficient written clinical documentation to support each therapy, service, activity, or session for which billing is made which, at a minimum, consists of:

(1) The specific service type rendered;

(2) The date, duration, and actual beginning and ending time (denoting a.m. or p.m.) during which the services were rendered;

(3) Name, title, credentials and signature of the person providing the services;

(4) A description of each encounter or service sufficient to document that the service was provided; and

(5) A description of the consumer's response to the intervention.

3008.4

The FSMHC shall execute a participation agreement with the District's Health Information Exchange (HIE) and utilize the HIE to receive and transmit protected health information for consumers in accordance with the District of Columbia Mental Health Information Act of 1978, effective Mar. 3, 1979 (D.C. Law 2-136, D.C. Official Code §§ 7-1201.01et seq.).

D.C. Mun. Regs. tit. 22, r. 22-A3008

Final Rulemaking published at 67 DCR 11929 (10/16/2020); amended by Final Rulemaking published at 71 DCR 14542 (11/29/2024)