Patient Record Requirements

(1) Each Facility shall have a specific policy and procedure outlining the Facility’s duties and responsibilities regarding any service recipient medical record requirements that are listed herein and in the minimum requirements of Chapter 0940-05-06. (2) Facilities shall organize and coordinate patient medical and billing records in a manner which demonstrates that all pertinent patient information is accessible to all appropriate staff and to TDMHSAS surveyors. (3) Should the licensee plan to close its operations, written notice shall be given to the patient or the new provider prior to the planned closure of the Facility. Patient medical records shall be transferred to the patient or to the new provider within ten (10) business days of the last scheduled visit of the patient. (4) The Facility shall ensure that adequate billing and medical records are maintained in accordance with T.C.A. § 33-2-403(e), (f), and (g). (5) Except as otherwise authorized by law, no person shall be admitted for treatment without written consent from the patient and, if applicable, parent, guardian, or responsible party. A documented, voluntary, written, program-specific informed consent to treatment from each patient at admission shall include: (a) Information about all treatment procedures, services, and other policies and regulation throughout the course of treatment, including clinic charges in the form of a fee agreement signed by the patient. This fee agreement shall include an explanation of MINIMUM PROGRAM REQUIREMENTS FOR NONRESIDENTIAL CHAPTER 0940-05-35 OFFICE-BASED OPIATE TREATMENT FACILITIES the financial aspects of treatment and the consequences of nonpayment of required fees, including the procedures for the patient (or patient’s legal representative) in the event they are unable to pay for treatment; (b) Consent to the individualized, prescribed therapy before dosing begins, including information about potential interactions with and adverse reactions to other substances, including those reactions that might result from interactions and adverse reactions to alcohol, other prescribed or over-the-counter pharmacological agents, other medical procedures and food; (c) Information to each patient that the goal of opioid treatment is stabilization of functioning; (d) Acknowledgement that the patient has been informed of the Facility’s rules regarding patient conduct and responsibilities; (e) Acknowledgement that the patient has been informed of client rights as found in 0940- 05-35-.18, as well as 0940-05-06-.06; (f) Information that at regular intervals, in full consultation with the patient, the program shall discuss the patient’s present level of functioning, course of treatment, and future goals; and (g) Information that the patient may choose to withdraw from or be maintained on the medication as the client desires unless medically contraindicated. (6) The patient’s medical chart shall also include documentation of the following: (a) Documentation that the patient’s initial screening and comprehensive assessment are completed and documented in the patient’s medical record prior to the development of the patient’s individualized treatment plan; (b) The individualized treatment plan, including any reviews, changes or amendments to the plan; (c) Documentation that services listed in the individualized treatment plan are available and have been provided or offered; (d) A record of correspondence with the patient, family members, and other individuals and a record of each referral for services and its results; (e) A discharge and aftercare plan pursuant to 0940-05-35-.06(9), including reasons for discharge and any referral. In the case of death, the reported cause of death shall be documented; and (f) Documentation of coordination of care should be present in those clinical situations which require consultations or coordination of care.