D.C. Mun. Regs. tit. 29, r. 29-4905

Current through Register 71, No. 45, November 7, 2024

Rule 29-4905 - TREATMENT RECORDS

4905.1

All phases of the client's treatment program and related information shall be reflected in the record.

4905.2

The treatment record shall include, but not be limited to, the following:

(a) Complete identification data, including Medicaid number and other third party payor information, if applicable.

(b) Medical history, initial and subsequent assessments and evaluations, and initial and subsequent Plans of Care,

(c) Brief progress notes, signed and dated: and

(d) Summaries of significant face-to face contact by each health care professional with the client, that are signed and dated by the health care professional, to readily identify and support Medicaid billing.

4905.3

Each Provider shall document each service provided to the client in the treatment record, at the time of the occurrence and include at a minimum the following information:

(a) Date of service;

(b) Name and location of the service provider; and

(c) Description of the service.

4905.4

Each Provider shall maintain and secure client treatment records.

4905.5

Each Provider shall establish procedures for safeguarding client information pursuant to 42 CFR 431.305, and shall ensure that, except as otherwise provided by federal or District law or rules, the use or disclosure of client information shall be restricted to purposes related to the administration of the Medicaid Program, as set forth in 42 CFR 431.302.

D.C. Mun. Regs. tit. 29, r. 29-4905

Emergency Rulemaking published at 48 DCR 8872 (September 21, 2001) [EXPIRED]; as amended by Final Rulemaking published at 49 DCR 247 (January 11, 2002)