Patient and Resident Records

(A) The Licensed or Approved Provider shall maintain separate records for each patient and resident in a secure and confidential manner consistent with state and federal law, including 42 CFR Part 2. Records shall be legible and up to date no later than five business days from the date of last patient or resident contact. (B) The written individual patient or resident record shall include, but not be limited to, the following information: (1) name, unique patient or resident identifier, date of birth, sex, race/ethnicity, relationship status, and primary language, if other than English; (2) name and contact information of the referring agency, court or person; (3) presenting problem(s); (4) all necessary authorizations, consents, and updates; (5) patient or resident assessment as required by 105 CMR 164.072; (6) insurance coverage information; (7) individual treatment plan and service plan reviews; (8) signed patient or resident confirmation of receipt of program policy manual, information regarding maintenance of client confidentiality, and contact information for the Department's Bureau of Substance Addiction Services complaint line; (9) signed and dated progress notes entered by patient's or resident's counselor after every patient and resident contact or attempted contact; (10) documentation of STD, TB, Viral Hepatitis, HIV/AIDS risk assessment; (11) documentation of STD, TB, Viral Hepatitis, HIV/AIDS education; (12) record of any threat made by patient or resident to harm self or another, and the action taken by Licensed or Approved Provider in response to threat(s); (13) record of multidisciplinary team reviews concerning patient or resident, including plan for coordination with other substance use disorder treatment, mental health, and physical health care services; (14) discharge summary; (15) aftercare service plan; record of attempts at post-discharge follow-up by letter, phone call, home visit or through contacts with aftercare providers; records of any warnings, disciplinary actions, grievances or complaints, and actions taken by Licensed or Approved Provider; (18) patient and resident fee information, including method by which fee was determined, and documentation of all fees paid by patient or resident; and (19) record of care coordination, including relevant releases of information. (C) Progress notes shall be current, legible, dated, and signed by the individual making the entry. Group counseling and educational-session progress notes may describe the session in general, but the patient's or resident's record must also include in each progress note specific comments on the patient's or resident's participation and progress in the group. (D) All patient or resident cases reviewed by a Clinician and Counselor shall receive a quarterly record review by his or her supervisor. Evidence of this review shall be documented in the clinical record. (E) All patient and resident records shall be marked confidential and kept in a secure, locked location, accessible only to authorized staff. Electronic records shall be secured through firewall and password protection and shall be accessible only to authorized staff. (F) Except as otherwise provided in 105 CMR 164.000 or by applicable state or federal law, access to patient and resident records shall be limited to the patient or resident or his or her designee pursuant to patient's or resident's written authorization, and to those staff members authorized by the administrator. The Licensed or Approved Provider shall have a written procedure regulating and controlling access to patient and resident records by staff members whose responsibilities require access. (G) Upon a patient's or resident's request, the Licensed or Approved Provider shall provide, in a timely manner, to the patient or resident, another Licensed or Approved Provider or other specifically authorized person: (1) The opportunity to inspect the patient's or resident's records; A copy of such record, except in circumstances described in 243 CMR 2.07(13)(e): Psychiatric Records governing licensed physicians engaged in the practice of psychiatry; and (3) A copy of any previously completed report required for third-party reimbursement. (H) The Department shall have access to patient and resident records for the purposes of reviews required under 105 CMR 164.000. The Licensed or Approved Provider shall obtain any signed consent from its patients or residents that it deems necessary to provide such access.