West Virginia Code of State Rules › Agency 69 - Health And Human Resources › Title 69 - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES › Series 69-11 - Medication-Assisted Treatment - Opioid Treatment Programs › Section 69-11-20 - Patient Records

Current through Register Vol. XLI, No. 28, July 12, 2024
20.1.
				Each MAT 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 medication approved
				for use in treatment of substance use disorder.
20.2. 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
				18.
20.3. All patient records shall
				be kept confidential in accordance with all applicable federal and state
				requirements.
20.4. All patient
				records shall be updated in a timely manner.
20.5. Information in the patient medical
				records shall be entered by designated program staff and approved by the
				program physician. Entries shall be legible and organized in an effective
				manner, allowing materials to be easily retrieved.
20.6. MAT program policies and procedures
				should ensure security of all records including electronic records, if
				any.
20.7. Individual patient
				records shall contain:
20.7.a. Identifying and
				basic demographic data and the results of the screening process;
20.7.b. Documentation of program compliance
				with the program's policy regarding prevention of multiple
				admissions;
20.7.c. An initial
				assessment report;
20.7.d. A
				narrative biopsychosocial history;
20.7.e. All physical and biopsychosocial
				assessments;
20.7.f. Medical
				reports including results of the physical assessment; family medical history;
				review of systems; laboratory reports, including results of required drug
				screens; results obtained from the Controlled Substances Monitoring Program
				database; and progress notes, including documentation of current dose and other
				dosage data;
20.7.g. Dated case
				entries of all significant contacts with patients, including a record of each
				counseling session in chronological order;
20.7.h. Dates and results of case conferences
				for patients;
20.7.i. The initial
				and post-admission individualized treatment plan of care, and any amendments,
				reviews or changes to the plans;
20.7.j. Documentation that the services
				listed in the individualized treatment plan of care are available and have been
				provided or offered;
20.7.k. 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 drug screens; results from the
				Controlled Substances Monitoring Program database; documentation of whether the
				patient was offered or accepted a detoxification treatment plan option; and any
				other significant change in treatment, both positive and negative;
20.7.l. Coordination of care agreements
				signed by the patient, program physician and primary counselor;
20.7.m. Documentation that the MAT program
				made a good faith effort to review whether the patient is enrolled in any other
				MAT program;
20.7.n. A record of
				correspondence with the patient, family members and other individuals and a
				record of each referral for services and its results;
20.7.o. A record of correspondence with other
				health care providers of the patient;
20.7.p. 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 was discussed with the patient;
20.7.q. Consent forms, releases of
				information, prescription documentation, travel, employment and take-home
				documentation; and
20.7.r. A
				closing summary, including reasons for discharge and any referral. In the case
				of death, the cause of death, if known, shall be documented.