10- 144 C.M.R. ch. 118, § 4.E

Current through 2024-51, December 18, 2024

Section 144-118-4.E - Client Records

09/01/07 4.E.1. The facility must develop and maintain a record-keeping system that includes a separate record for each client. All reports and records must be available for inspection by the Department upon request.

09/01/07 4.E.2. Documentation in the record must include:

a. Health Care Services (if appropriate):

1. Medical care plan and progress notes; or nursing/health care plan and progress notes; and

2. Medication administration and response to drugs

b. Active Treatment:

09/01/07

1.Annual Plan

2. Written training plans;

3. Reviews, as appropriate, by a member of the IDT;

4. Professional evaluations and recommendations for treatment; and

5. Reports from external and day programs;

6. Ensure that the updated comprehensive functional assessment and the reviewed and revised IPP is placed in the client's record, together with:

(a) New and revised habilitation plans and programs; and

(b) All reports and evaluations which contributed to the development of the new plan including, but not limited to:

(1) Social Services progress notes;

(2) Activities assessments and summaries;

(3) Annual evaluations with progress notes and recommendations by all professions whose expertise encompasses areas in which the client does not function appropriately;

(4) Physician's statement of current status and evaluation of progress;

(5) Psychological evaluation with summary of developmental and behavioral progress/problems and recommendations;

(6) Pharmacist's drug regimen reports;

(7) Nursing summary of progress/problems and recommendations; and

c. Social Information:

1. Plan of care and progress notes;

2. Discharge plan;

3. Record of family involvement; and

4. Activities assessment.

d. Protection of Clients Rights:

1. Acknowledgment of client or his/her legal representative having read or heard the statement of rights;

2. If anyone other than the facility or appropriate governmental agency staff is to have access, written permission from the client or his/her legal representative for that person;

3. Personal property inventory; and

4. Appropriate authorizations and consents by clients, parents, or legal guardians.

e. In addition to the above, the record for each client admitted will contain:

1. Initial assessments, progress reports, the most recent individual program plan and current information for the past twelve (12) months;

2. Name, date of admission, birth date and place of birth, citizenship status and social security number;

3. Parent(s) names, birthplaces and marital status, if known;

4. Name, address and telephone number of parent(s), legal guardian, correspondent and, if needed, next of kin;

5. Sex, race, height, weight, color of hair, color of eyes, identifying marks and recent photograph;

6. Language spoken and understood, and religious affiliation;

7. Preadmission evaluation and medical history;

8. Physician(s) orders for medication and other prescribed treatment;

9. Physician certification for appropriate level of care;

10. Reason for referral for admission as documented by the Preplacement Interdisciplinary Team;

11. Type and legal status of admission;

12. Legal competency status;

13. All sources of financial support;

14. Records of significant behavior incidents;

15. Records of any allegation or instance of abuse, neglect or exploitation of the client if appropriate, with documentation of resolution;

16. Reports of accidents, seizures, illness and treatments for these conditions;

17. Records of all periods that restraints were used, with justification and authorization for each;

18. Correspondence pertaining to the client;

19. Records of immunizations; and

20. Contracts between the client and the facility.

4. E. 3. The facility shall keep confidential all information in client records regardless of form or method of storage, including information contained in an automated data bank. The client or his/her legally designated guardian shall have access to the records (unless medically contraindicated as documented by the physician in the medical record) in the presence of a member of the facility staff.

10- 144 C.M.R. ch. 118, § 4.E