ARM 37.106.1454. CLIENT RECORD CONTENT REQUIREMENTS

(1) The service provider must ensure client record content 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) documentation the client was informed of federal confidentiality requirements and received a copy of the client notice; (e) assurance all clients have an orientation to the program's treatment services, infectious disease information, and disaster plan; (f) voluntary consent to treatment signed and dated by the client or legal guardian; (g) treatment plan; (h) progress notes; (i) discharge summary; (j) medication records, if applicable; (k) laboratory reports, if applicable; (l) properly completed authorizations for release of information; (m) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and (n) documentation showing client received a copy of client grievance policies and procedures.