R432-102-14. Patient Record

(1) Refer to R432-100-33, Medical Records.

(2) The content of the patient record shall contain in addition:

(a) progress notes, including description and date of service, with a summary of client progress, signed by the therapist or service provider;

(b) a discharge summary, including final evaluation of treatment and goals attained and signed by the therapist.

(3) A written individual treatment plan shall be initiated for each patient upon admission and completed no later than seven working days after admission.

(a) The individual treatment plan shall be part of the patient record and signed by the person responsible for the patient's care. Patient care shall be administered according to the individual treatment plan.

(b) Individual treatment plans must be reviewed on a weekly basis for the first three months, and thereafter at intervals determined by the treatment team, but not to exceed every other month.

(c) The written individual treatment plan shall be based on a comprehensive functional medical, psycho-social, substance abuse, and treatment history assessment of each patient. When appropriate, the patient and family shall be invited to participate in the development and review of the individual treatment plan. Patient and family participation shall be documented.

(d) The individual treatment plan shall be available to all personnel who provide care for the patient.

(e) The Utah State Hospital is exempt from the time frames for initiating and reviewing the individual treatment plan. The Utah State Hospital shall initiate for each patient admitted an individual treatment plan within 14 days and shall review the plan on a monthly basis.

(4) The confidentiality of the records of substance abuse patients shall be maintained according to the federal guidelines is adopted and incorporated as reference 42 CFR, Part 2, "Confidentiality of Alcohol and Drug Abuse Patient Records."