Current through Register Vol. XLI, No. 50, December 13, 2024
Section 69-7-25 - Patient Records25.1. 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.; and25.7.o. A closing summary, including reasons for discharge and any referral. In the case of death, the cause of death shall be documented.