Section 25. Client Records

The facility must develop and maintain a record keeping system that includes a separate record for each client which documents the client's health care, active treatment, social information, and protection of the client's rights. As a minimum the client's record must contain: A. Personal information: (1) full name; (2) date of birth; (3) social security number; (4) height; (5) weight; (6) color of hair; (7) color of eyes; (8) identifying marks and recent photograph; (9) full name of parents and their dates of birth; (10) language(s) spoken and understood and language used in the natural home; (11) information relevant to religious preference; (12) legal documentation relevant to commitment or guardianship status; (13) name, address, and telephone number of next-of-kin, other person or agency to contact in case of an emergency. B. Medical information: (1) reports of previous histories, evaluations or observations; (2) age at onset of disability; (3) name, address and telephone number of physician or health facility providing medical care; (4) medication history, including present medication dosage and schedule; (5) reports of all treatments, etc. C. Individual habilitation plan: Each client must have an individual habilitation plan which specifies goals and objectives. D. Admission agreement. [8.371.2.26 NMAC - N, 7/1/2024}