N.M. Admin. Code § 8.321.10.28

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.321.10.28 - PATIENT RECORDS

A. The OTP 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 requirements relevant to OTPs and to confidentiality of patient records.

B. Each patient record shall include:

(1) the results of the physical examination;

(2) the results of all assessments;

(3) the treatment plan and all updates or revisions;

(4) the results of laboratory tests and a description of any action taken based upon the results;

(5) documentation of the patient's current dose and dosage history;

(6) documentation of counseling provided to the patient;

(7) dates and results of meetings or conferences regarding the patient's treatment;

(8) documentation of the process used and factors considered in making decisions that impact a patient's treatment, such as whether to allow take-home medication and the frequency of laboratory drug detection tests; and

(9) documentation of the agency's efforts to learn of multiple opioid treatment program enrollment;

(10) documentation that the patient has received and understood information regarding the harmful effects of diversion of opioid treatment medication.

N.M. Admin. Code § 8.321.10.28

Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024