Section 246-341-1015 - Opioid treatment programs (OTP) - Individual service record content and documentation requirementsAn agency providing opioid treatment program services must maintain an individual's individual service record. The individual service record must contain:
(1) Documentation that the agency made a good faith effort to review if the individual is enrolled in any other opioid treatment program and take appropriate action;(2) Documentation that the individual received a copy of the rules and responsibilities for treatment participants, including the potential use of interventions or sanction;(3) Documentation that the individual service plan was reviewed quarterly and semi-annually after two years of continuous treatment;(4) Documentation when an individual refuses to provide a drug testing specimen sample. The refusal is considered a positive drug screen specimen;(5) Documentation in progress notes of timely interventions used to therapeutically address the disclosure of illicit drug use, a positive drug test, or possible diversion of opioid medication, as evidenced by the absence of opioids or related metabolites in drug toxicology test results;(6) Documentation of all medical services including:(a) Results of physical examination;(b) Medical and family history;(d) Laboratory reports including results of regular toxicology screens, a problem list, and list of medications updated as clinically indicated; and(e) Progress notes including documentation of all medications and dosages, if available.Wash. Admin. Code § 246-341-1015
Adopted by WSR 19-09-062, Filed 4/16/2019, effective 5/17/2019Amended by WSR 21-12-042, Filed 5/25/2021, effective 7/1/2021Amended by WSR 22-24-091, Filed 12/6/2022, effective 12/10/2022 and 5/1/2023