Cal. Code Regs. tit. 9 § 10165

Current through Register 2024 Notice Reg. No. 50, December 13, 2024

Section 10165 - Content of Patient Records

(a) Each program shall document the following information in the individual patient's records:

(1) The patient's birth date.

(2) Physical examination data, including laboratory results for required tests and analyses.

(3) Evidence of current use of opioids.

(4) Date of admission to the program, plan of treatment, and medication orders signed by the physician.

(5) The program's response to a test or analysis for illicit drug use which discloses the absence of both methadone and its primary metabolite (when prescribed by the medical director and program physician), the presence of any illicit drugs, or abuse of other substances, including alcohol.

(6) Known arrests, convictions or any other signs of retrogression.

(7) Any other patient information which the program finds useful in treating the patient.

(b) In addition to the requirements set forth in subsection (a) above, records for patients in detoxification shall contain the following:

(1) Documentation of services and treatment provided, as well as progress notes signed by the physician, nurse, or counselor, test or analysis results for illicit drug use; and periodic review or evaluation by the medical director.

(2) For patients who have completed the program, a discharge summary and follow-up notations to allow determination of treatment outcomes and follow-up.

(c) In addition to the requirements set forth in subsection (a) above, for patients in maintenance treatment records shall contain the following:

(1) Documentation of prior addiction and prior treatment outcomes.

(2) Documentation of services and treatment provided, as well as progress notes, signed by the physician, nurse, or counselor; test or analysis results for illicit drug use and periodic review or evaluation by the medical director. Such review shall be made not less than annually.

(3) For any patient who is to be continued on maintenance treatment beyond one year, the circumstances justifying such continued treatment as set forth in Section 10410.

(4) Reasons for changes in dosage of levels and medications.

(5) For patients who have terminated the program, a discharge summary and follow-up notations to allow determination of treatment outcomes.

Cal. Code Regs. Tit. 9, § 10165

1. Change without regulatory effect renumbering and amending parts of former sections 10316-10320 to 10165 filed 6-3-91 pursuant to section 100, title 1, California Code of Regulations (Register 91, No. 34).
2. Amendment of section and NOTE filed 3-15-96 as an emergency; operative 3-15-96 (Register 96, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-13-96 or emergency language will be repealed by operation of law on the following day.
3. Amendment of section and NOTE refiled 7-8-96 as an emergency; operative 7-12-96 (Register 96, No. 28). A Certificate of Compliance must be transmitted to OAL by 11-12-96 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section and NOTE refiled 10-23-96 as an emergency; operative 10-29-96 (Register 96, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-26-97 or emergency language will be repealed by operation of law on the following day.
5. Amendment of section and NOTE refiled 2-11-97 as an emergency; operative 2-24-97 (Register 97, No. 7). A Certificate of Compliance must be transmitted to OAL by 6-24-97 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 2-11-97 order transmitted to OAL 3-4-97; disapproved by OAL and order of repeal as to 2-11-97 order filed 4-15-97 (Register 97, No. 16).
7. Amendment of section and NOTE filed 4-15-97 as an emergency; operative 4-15-97 (Register 97, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-13-97 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 4-15-97 order, including amendment of subsections (a)(2), (a)(4) and (a)(5), transmitted to OAL 6-2-97 and filed 6-13-97 (Register 97, No. 24).
9. Change without regulatory effect amending NOTE filed 4-19-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 16).
10. Amendment of section and NOTE filed 5-7-2020; operative 7-1-2020 (Register 2020, No. 19).

Note: Authority cited: Sections 11750, 11755, 11835, 11839.3 and 11839.20, Health and Safety Code. Reference: Sections 11839.3 and 11839.20, Health and Safety Code.

1. Change without regulatory effect renumbering and amending parts of former sections 10316-10320 to 10165 filed 6-3-91 pursuant to section 100, title 1, California Code of Regulations (Register 91, No. 34).
2. Amendment of section and Note filed 3-15-96 as an emergency; operative 3-15-96 (Register 96, No. 11). A Certificate of Compliance must be transmitted to OAL by 7-13-96 or emergency language will be repealed by operation of law on the following day.
3. Amendmentof section and Note refiled 7-8-96 as an emergency; operative 7-12-96 (Register 96, No. 28). A Certificate of Compliance must be transmitted to OAL by 11-12-96 or emergency language will be repealed by operation of law on the following day.
4. Amendment of section and Note refiled 10-23-96 as an emergency; operative 10-29-96 (Register 96, No. 43). A Certificate of Compliance must be transmitted to OAL by 2-26-97 or emergency language will be repealed by operation of law on the following day.
5. Amendment of section and Note refiled 2-11-97 as an emergency; operative 2-24-97 (Register 97, No. 7). A Certificate of Compliance must be transmitted to OAL by 6-24-97 or emergency language will be repealed by operation of law on the following day.
6. Certificate of Compliance as to 2-11-97 order transmitted to OAL 3-4-97; disapproved by OAL and order of repeal as to 2-11-97 order filed 4-15-97 (Register 97, No. 16).
7. Amendment of section and Note filed 4-15-97 as an emergency; operative 4-15-97 (Register 97, No. 16). A Certificate of Compliance must be transmitted to OAL by 8-13-97 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 4-15-97 order, including amendment of subsections (a)(2), (a)(4) and (a)(5), transmitted to OAL 6-2-97 and filed 6-13-97 (Register 97, No. 24).
9. Change without regulatory effect amendingNote filed 4-19-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 16).
10. Amendment of section and Note filed 5-7-2020; operative 7/1/2020 (Register 2020, No. 19).