Section He-M 408.04 - Clinical Record Components(a) The clinical record shall be designed to:(1) Document the medical necessity for services provided;(2) Document the response to and effectiveness of services;(3) Document the extent of coordination of care by system-wide providers and, when appropriate, with providers outside the mental health system; and(4) Provide documentation substantiating the delivery and appropriateness of services as required by He-M 401 and He-M 426.(b) The clinical record shall include, at a minimum, the following components: (1) Intake and assessment information in accordance with He-M 408.06;(2) Demographic data in accordance with He-M 408.05;(3) Annual notification of an individual's rights in accordance with He-M 309;(4) Documentation of eligibility determination in accordance with He-M 401;(5) Individual service planning documentation pursuant to He-M 401;(6) Individual service plan;(7) Documentation of service delivery and outcomes;(8) Suspension, transfer, and discharge notes, if applicable;(9) Documentation of ISP reviews;(10) Medication orders, laboratory results, and general health information;(11) Pertinent legal data;(12) Admission and discharge reports from mental health facilities and from other providers, when applicable; and(13) Targeted case management assessment and care plan pursuant to He-M 426, which shall include documentation of the following, when applicable: a. Identification of the individual's targeted case management needs;b. The referral and monitoring activities to be provided; andc. An individual's refusal to receive specific services in the care plan.N.H. Admin. Code § He-M 408.04
#2039, eff 7-1-82; ss by #2423, eff 7-13-83; rpld by #2468, eff 9-6-83
New. #3051, eff 7-8-85, EXPIRED: 7-8-91
New. #7281, eff 5-23-00, EXPIRED: 5-23-08
New. #9512, eff 7-9-09
Amended by Volume XXXVII Number 45, Filed November 09, 2017, Proposed by #12409, Effective 10/24/2017, Expires 10/24/2027.