37.106.1454    CLIENT RECORD CONTENT REQUIREMENTS

(1) The substance use disorder residential facility (SUDF) must develop and implement procedures to ensure each client record is available on-site and includes:

(a) demographic information;

(b) a substance related disorder diagnosis and supporting documentation for diagnosis;

(c) biopsychosocial assessment including diagnosis showing the rationale for admission;

(d) signed documentation the client was informed of federal confidentiality requirements and received a copy of the client notice as required in ARM 37.106.1416;

(e) signed documentation the client received orientation to the SUDF's treatment services, infectious disease information, and disaster plan described in ARM 37.106.322;

(f) a voluntary consent to treatment signed and dated by the client or legal guardian;

(g) individualized treatment plan and treatment plan reviews;

(h) progress notes;

(i) clinical notes;

(j) continuing care plan; 

(k) medication records, if applicable;

(l) laboratory reports, if applicable;

(m) authorizations for release of information, as needed;

(n) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and

(o) documentation pertaining to client receipt of grievance policies and procedures.

(p) documentation of any client-filed written grievances and resolution;

(q) documentation the client received a copy of the client rights policy and the client's signature indicating he/she received the policy; and

(r) documentation of school educational courses attended or provided.

 

History: 50-5-103, 53-24-208, MCA; IMP, 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA; NEW, 2010 MAR p. 2975, Eff. 12/24/10; AMD, 2022 MAR p. 2040, Eff. 9/24/22.