W. Va. Code R. § 69-12-18
Current through Register Vol. XLI, No. 50, December 13, 2024
Section 69-12-18 - Patient Records18.1. 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; and18.5.12. 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; and18.6.5. A plan for action or further treatment.W. Va. Code R. § 69-12-18