R523-3-9. Documentation Standards for Substance Use Disorder and Co-occurring Treatment

  (1) A complete and accurate record of all clinical services shall be kept for each youth served that contains the following information:

  (a) Any and all screenings and assessments completed;

  (b) Any and all consent forms or required disclosures;

  (c) A comprehensive treatment plan;

  (d) Progress notes;

  (e) Continuing recovery recommendations upon discharge; and

  (f) Record reflects cultural and gender specificity in treatment.

  (2) The youth record is maintained in a manner so as to protect confidentiality and comply with 42 CFR Part 2 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) documentation/privacy standards. The record is organized, clear, complete, current and legible.

  (a) Consent forms for any release of information shall be found in the file.

  (b) Consent forms shall be complete, and contain a statement that consent is subject to revocation, shall be signed and dated by the patient, and guardian if the patient is a minor.

  (c) Each file shall contain a signed and witnessed Acknowledgement of Receipt of Privacy statement.

  (3) The youth record shall contain documentation of the initial assessment/engagement session.

  (a) The assessment/engagement identifies presenting problem(s), youth goals and identifies the initial diagnosis.

  (b) The assessment/engagement includes a statement of the youth's presenting problem(s) and:

  (i) Identification and documentation of acute psychosis, intoxication/withdrawal relevant to the presenting problem;

  (ii) Identification and documentation of biomedical conditions and complications relevant to the presenting problem;

  (iii) Identification and documentation of emotional; behavioral, cognitive conditions and or complications relevant to the youth's current situation and the presenting problem;

  (iv) Identification, evaluation and documentation of the readiness to change relevant to the presenting problem;

  (v) Identification and documentation of relapse, or continued problem potential relevant to the presenting problem;

  (vi) Identification and documentation of the youth's recovery environment relative to the presenting problem;

  (vii) Identification of recovery support services needed relevant to the presenting problem;

  (viii) An assessment/engagement summary includes recommendations for level of care and intensity of services needed; and

  (ix) Documentation of an assignment for the youth to complete for their next session.

  (4) Any and all screenings and assessments shall be documented in the youth file.

  (a) The assessment information is current and includes the justification for the assessed level of care and array of services, as well as justification if the level of care is being substituted.

  (b) Assessment dimensions are current and are updated as new information is received, new goals are identified and youth progresses or regresses.

  (c) Assessment process is ongoing and changes to assessment information are reflected throughout the record.

  (d) Level of care and intensity of services are supported by ongoing assessment information, or difference is clinically justified.

  (e) Assessment shall be signed and include the title of a person licensed in the State of Utah to diagnose, assess and treat people with mental health and substance use disorders.

  (5) A treatment plan that contains the following:

  (a) Specific individualized long range goals;

  (b) Behaviorally measurable short-term objectives that support long range goals;

  (c) Evidence of youth's participation in development of the plan;

  (d) Evidence that the plan is based on the youth's goals and other needs identified in the screening and assessments;

  (e) Objectives that are measurable, achievable within a specified time frame and reflect developmentally appropriate activities that support progress towards achievement of youth goals;

  (f) Substance use disorder treatment plans should be based on the six ASAM Patient Placement Dimensions and shall address critical areas identified in each dimension. Mental Health Recovery Plans shall be organized in a similar manner;

  (g) Interventions designed to help the patient complete the objectives; and

  (h) Signature and title of a person licensed in the State of Utah to diagnose, assess and treat people with mental health and substance use disorders.

  (6) The youth file shall include documentation of the youth's status throughout the youth record including:

  (a) Changes in types, schedule, duration and frequency of therapeutic interventions to facilitate youth progress as well as changes in youth objectives and goals;

  (b) Each contact shall be documented in a timely manner:

  (c) Progress notes shall be kept that identify the date, duration and type of intervention;

  (d) Progress notes shall document progress or lack of progress on the youth's goals as well as the clinician's assessment of the youth's changes in behaviors, attitudes and beliefs;

  (e) Progress notes shall reflect clinician's assessment of the effectiveness of the therapeutic interventions and plans for future interventions;

  (f) Notes shall be legible and signed by a qualified staff indicating appropriate credentials;

  (g) No-shows, cancellations or gaps in service such as vacation, incarceration, home visits shall be documented;

  (h) Youth and group notes shall be specific and document progress towards achievement of the objectives identified in the treatment plan and as each objective is completed, identify a new objective;

  (i) Lack of progress toward treatment/recovery plan goals and resulting adjustments to the recovery plan shall also be documented;

  (j) Notes shall reflect behavioral changes as well as changes in attitudes and beliefs;

  (k) Other group activities such as psychoeducation, life skills, case management, and recreation may be summarized and dated with the date the activity occurred;

  (l) Recovery support services are documented to the extent required for clinical continuity and in order to meet financial requirements;

  (m) Changes in assessment information, current level of care and treatment plan; and

  (n) Upon discharge, recommendations for ongoing services include the extent to which established goals and objectives were achieved, what ongoing services are recommended, and a description of the youth's recovery support plan.