W. Va. Code R. § 69-11-20

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 69-11-20 - Patient Records

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.

W. Va. Code R. § 69-11-20