D.C. Mun. Regs. r. 22-A8023

Current through Register Vol. 71, No. 25, June 21, 2024

Rule 22-A8023 - RECORD CONTENTS

8023.1

As applicable, all records shall include:

(a) Documentation of the referral and initial screening and its findings;

(b) The individual's consent to services (if applicable);

(c) A copy of the Application for Emergency Hospitalization ("FD-12")(if applicable);

(d) The Rights Statement;

(e) Documentation that the individual received:

(i) An orientation to the program's services, rules, confidentiality practices, and individual's rights; and

(ii) Notice of privacy practices and opt-out form.

(f) Confidentiality forms and releases signed to permit the facility to obtain and/or release information;

(g) Diagnostic interview and assessment record, including any Department-approved screening and assessment tools;

(h) Evaluation of medical needs and, as applicable, medication intake sheets and special diets which shall include:

(i) Documentation of physician's orders for medication and treatment, change of orders, and/or special treatment evaluation;

(ii) For drugs prescribed following admissions, any prescribed drug product by name, dosage, and strength, as well as date(s) medication was administered, discontinued, or changed; and

(iii) For any prescribed over-the-counter ("OTC") medications following admissions, any OTCs by product name, dosage, and strength, as well as date(s) medication was administered, discontinued, or changed.

(i) Assessments and individual treatment plans pursuant to the presenting behavioral health situation and the individual's needs, including crisis diversion or safety plans, if applicable;

(j) Encounter notes, which provide sufficient written documentation to support each therapy, service, activity, or session for which billing is made that, at a minimum, consists of:

(i) The specific service type rendered;

(ii) Dated and authenticated entries with their authors identified, that include the duration, and actual time (beginning and ending as well as a.m. or p.m.), during which the services were rendered. To constitute a valid signature, digital signatures must include a date and time stamp contemporaneous with the signature function and must be recorded and readily retrievable in the electronic system's audit log;

(iii) Name, title, and credentials of the person providing the services;

(iv) The setting in which the services were rendered;

(v) Confirmation that the services delivered are contained in the individual's record and are identified in the encounter note;

(vi) A description of each encounter or intervention provided to the individual, which is sufficient to document that the service was provided in accordance with this chapter;

(vii) A description of the individual's response to the intervention sufficient to show, particularly in the case of group interventions, the individual's unique participation in the service; and

(viii) Provider's observations.

(k) Documentation of all services provided to the individual as well as activities directly related to the individual's care that are not included in encounter notes;

(l) Documentation of missed appointments and efforts to contact and reengage the individual;

(m) Documentation of any personal articles of the individual held by the provider for safekeeping and any statements acknowledging receipt of the property;

(n) Documentation of all referrals to other agencies and the outcome of such referrals if known;

(o) Documentation establishing all attempts to acquire necessary and relevant information from other sources;

(p) Pertinent information reported by the individual, family members, or significant others regarding a change in the individual's condition and/or an unusual or unexpected occurrence in the individual's life;

(q) Drug test results and incidents of drug use;

(r) Discharge summary and aftercare plan;

(s) Outcomes of care and follow-up data concerning outcomes of care;

(t) Documentation of correspondence including with other medical providers, community providers, human services, social service, and criminal justice entities pertaining to an individual's treatment and follow-up services; and

(u) Documentation of an individual's legal guardian, as applicable.

D.C. Mun. Regs. r. 22-A8023

Final Rulemaking published at 68 DCR 1623 (2/5/2021)