West Virginia Code of State Rules › Agency 69 - Health And Human Resources › Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 69-07 - Regulations of Opioid Treatment Programs › Section 69-7-25 - Patient Records

Current through Register Vol. XLI, No. 28, July 12, 2024
25.1.
				Each opioid treatment program shall establish and maintain a recordkeeping
				system that is adequate to document and monitor patient care. The system shall
				comply with all federal and state reporting requirements relevant to opioid
				drugs approved for use in treatment of opioid addiction.
25.2. All patient records shall be maintained
				for a minimum of five years from the time that the documented treatment is
				provided. In the event a patient is a juvenile, the records shall be kept for a
				minimum of five years from the time the patient reaches the age of eighteen
				years.
25.3. All patient records
				shall be kept confidential in accordance with all applicable federal and state
				requirements.
25.4. All patient
				records shall be updated in a timely manner.
25.5. Information in the patient medical
				records shall be entered only by physicians and other licensed health
				professionals. Entries shall be legible and organized in an effective manner,
				allowing materials to be easily retrieved.
25.6. Opioid treatment program procedures
				should ensure security of all records including electronic records, if
				any.
25.7. Individual patient
				records shall contain:
25.7.a. Identifying and
				basic demographic data and the results of the screening process;
25.7.b. Documentation of program compliance
				with the program's policy regarding prevention of multiple
				admissions;
25.7.c. An initial
				assessment report;
25.7.d. A
				narrative bio-psychosocial history completed within thirty days of the
				patient's admission;
25.7.e.
				Medical reports including results of the physical examination; past and family
				medical history; review of systems; laboratory reports, including results of
				required toxicology screens; results obtained from the Controlled Substances
				Monitoring Program database; and progress notes, including documentation of
				current dose and other dosage data;
25.7.f. Dated case entries of all significant
				contacts with patients, including a record of each counseling session in
				chronological order;
25.7.g. Dates
				and results of case conferences for patients;
25.7.h. The initial and post-admission
				individualized treatment plans of care, and any amendments, reviews or changes
				to the plans;
25.7.i. Documentation
				that the services listed in the individualized treatment plan of care are
				available and have been provided or offered;
25.7.j. A written report of the treatment
				process; factors considered in decisions impacting patient treatment (e.g.,
				take-home medication privileges, changes in counseling sessions, changes in
				frequency of toxicology screens; results from the Controlled Substances
				Monitoring Program database); documentation of whether the patient was offered
				or accepted a detoxification treatment plan option; or any other significant
				change in treatment, both positive and negative;
25.7.k. Documentation that the opioid
				treatment program made a good faith effort to review whether the patient is
				enrolled in any other opioid treatment program;
25.7.l. A record of correspondence with the
				patient, family members and other individuals and a record of each referral for
				services and its results;
25.7.m.
				Documentation that the patient was provided with a copy of the program's rules
				and regulations; a copy of the patient's rights and responsibilities; a copy of
				the detoxification treatment plan option, if applicable; a copy of the
				patient's individualized treatment plan of care; a copy of the patient's goals;
				and documentation that each of these items were discussed with the
				patient;
25.7.n. Consent forms,
				releases of information, prescription documentation, travel, employment and
				"take-home" documentation, etc.; and
25.7.o. A closing summary, including reasons
				for discharge and any referral. In the case of death, the cause of death shall
				be documented.