N.M. Admin. Code § 8.321.11.28

Current through Register Vol. 35, No. 22, November 19, 2024

Section 8.321.11.28 - CLIENT CLINICAL RECORD

The client clinical records maintained by a crisis triage center in a paper-based or electronic system shall document the degree and intensity of the treatment provided to clients who are furnished services by the CTC. A client's clinical record shall contain at a minimum:

A. the client's name and address;

B. name, address, and telephone number of agent, or representatives;

C. the source of referral and relevant referral information;

D. all reports from client assessment (see program services assessment);

E. the signed and dated informed consent for treatment including all medications and transfers;

F. all additional medical and clinical documentation;

G. the original crisis stabilization plan and all revisions;

H. documentation of all treatment;

I. laboratory and radiology results, if applicable;

J. documentation of physical restraint observations, if utilized;

K. a record of all contacts with medical and other services;

L. a record of medical treatment and administration of medication, if administered;

M. an original or original copy of all physician medication and treatment orders signed by the physician;

N. signed consent for the release of information, if information is released;

O. discharge plan.

N.M. Admin. Code § 8.321.11.28

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