N.M. Admin. Code § 8.371.2.25

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

Section 8.371.2.25 - CLIENT RECORDS

The facility must develop and maintain a record keeping system that includes a separate record for each client which documents the client's health care, active treatment, social information, and protection of the client's rights. As a minimum the client's record must contain:

A. Personal information:

(1) full name;

(2) date of birth;

(3) social security number;

(4) height;

(5) weight;

(6) color of hair;

(7) color of eyes;

(8) identifying marks and recent photograph;

(9) full name of parents and their dates of birth;

(10) language(s) spoken and understood and language used in the natural home;

(11) information relevant to religious preference;

(12) legal documentation relevant to commitment or guardianship status;

(13) name, address, and telephone number of next-of-kin, other person or agency to contact in case of an emergency.

B. Medical information:

(1) reports of previous histories, evaluations or observations;

(2) age at onset of disability;

(3) name, address and telephone number of physician or health facility providing medical care;

(4) medication history, including present medication dosage and schedule;

(5) reports of all treatments, etc.

C. Individual habilitation plan: Each client must have an individual habilitation plan which specifies goals and objectives.

D. Admission agreement.

N.M. Admin. Code § 8.371.2.25

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