Service Recipient Record Requirements

(1) Facilities shall organize and coordinate service recipient records in a manner which demonstrates that all pertinent service recipient information is accessible to all appropriate staff and to the SOTA and TDMHSAS. (2) All documentation will be clearly dated and initialed or signed by the staff member involved. (3) Records shall be preserved in accordance with T.C.A. § 33-3-101(d). The records may be generated, maintained, or transferred in whole or in part to any recording medium that assures accurate preservation of the record. (4) The Facility shall discuss final storage or disposition of the Facility’s records with TDMHSAS ninety (90) days in advance of the closing of a Facility. MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (5) The service recipient’s records shall include, but not be limited to, the following documentation: (a) A voluntary, written, Facility-specific informed consent to treatment from each service recipient at admission to include: 1. Information about all treatment procedures, services, and other policies and regulations throughout the course of treatment shall be presented to the patient. This information shall include clinic charges in the form of a fee agreement that is signed, either in person or electronically, by the service recipient; 2. Acknowledgment of the individualized, prescribed therapy before dosing begins, including information about potential interactions with and adverse reactions to other substances, including interactions and adverse reactions to alcohol, other prescribed medications, over-the-counter medications, other medical procedures, and food; 3. Information that the goal of opioid treatment is stabilization of functioning; 4. Information that short-term withdrawal management from opioids over thirty (30) to one hundred eighty (180) days is a treatment alternative to long-term maintenance, if available; 5. Acknowledgment that the service recipient has been informed of the Facility’s rules regarding service recipient conduct and responsibilities and continuing documentation of the service recipient’s compliance with the Facility’s policies; 6. Acknowledgment that the service recipient has been informed of their rights (Rule 0940-05-42-.27); 7. Information that, at regular intervals and in full consultation with the service recipient, the Facility shall discuss the service recipient’s present level of functioning, course of treatment and future goals; and 8. Information that the service recipient may choose to withdraw from or be maintained on the medication as they desire, unless medically contraindicated. (b) Documentation of the initial and comprehensive assessments as required by Paragraphs 0940-05-42-.06(8) and (9); (c) Medical reports including results of the physical examination; past and family medical history; review of systems; laboratory reports, including results of required toxicology screens; and progress notes, including documentation of current dose and other dosage data. Information in the medical record shall be entered by a program provider and other licensed health professionals. The service recipient’s medical record may also include clinical data obtained from outside medical providers with the patient’s written consent; (d) Dated and signed case entries of all significant contacts with service recipients, including a record of each counseling session in chronological order; (e) Dates and results of treatment team meetings for service recipients; MINIMUM PROGRAM REQUIREMENTS FOR NON-RESIDENTIAL CHAPTER 0940-05-42 OPIOD TREATMENT PROGRAM FACILITIES (f) The initial treatment plan, any amendments to the plan, reviews of the plan, and the long-term, individualized treatment plan, including any amendments to that document and reviews of the plan; (g) Documentation that services listed in the plan are available and have been provided or offered; (h) Documentation that the service recipient was informed about the process and factors considered in decisions impacting the service recipient’s treatment (for example, take- home medication privileges, changes in counseling sessions, changes in frequency of toxicology screens); (i) A record of correspondence with the service recipient, family members and other individuals and a record of each referral for services and its results; (j) Documentation that the service recipient was provided a copy of the Facility’s rules and regulations and a copy of the service recipient’s rights and responsibilities and that these items were discussed with them; (k) A closing summary, including reasons for discharge and any referral. In the case of death, the reported cause of death shall be documented; (l) A written fee agreement as detailed in Rule 0940-05-42-.06 dated and signed by the service recipient, or the service recipient’s legal representative, prior to provision of any services. This fee agreement shall include an explanation of the financial aspects of treatment and the consequences of nonpayment of required fees, including the procedures for medically supervised withdrawal in the event that a service recipient becomes unable to pay for treatment. If the service recipient’s financial responsibility changes, a new fee agreement shall be signed, either in person or electronically, prior to the provision of further services; (m) Documentation of Central Registry clearance as required under these rules; and (n) All other information and documents as required by the SOTA and these rules.