Section R432-102-14 - Patient Record(1) Section R432-100-35, Medical Records, applies to a substance use disorder specialty hospital.(2) The licensee shall ensure the content of the patient record contains: (a) progress notes, including description and date of service, with a summary of client progress, signed by the therapist or service provider; and(b) a discharge summary, including final evaluation of treatment and goals attained and signed by the therapist.(3) The licensee shall ensure: (a) a written individual treatment plan is initiated for each patient upon admission and completed within seven working days following admission;(b) the individual treatment plan is part of the patient record and signed by the responsible party for the patient's care;(c) patient care is administered according to the individual treatment plan;(d) individual treatment plans are reviewed on a weekly basis for the first three months, and at intervals determined by the treatment team, but not to exceed every other month;(e) the written individual treatment plan is based on a comprehensive functional medical, psycho-social, substance use, and treatment history assessment of each patient;(f) when appropriate, the patient and family is invited to participate in the development and review of the individual treatment plan and any patient and family participation is documented; and(g) the individual treatment plan is available to any personnel who provide care for the patient.(4) The Utah State Hospital is exempt from the time frames listed in Subsection R432-102-14(3)(a) for initiating and reviewing the individual treatment plan and shall initiate an individual treatment plan for each patient admitted within 14 days and review the plan on a monthly basis.(5) The licensee shall ensure the confidentiality of the records of substance use disorder patients are maintained according to The Code of Federal Regulations, Title 42, Part 2, Confidentiality of Substance Use Disorder Patient Records.Utah Admin. Code R432-102-14
Amended by Utah State Bulletin Number 2023-16, effective 7/28/2023