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28 Pa. Code § 715.23. Patient records.

§ 715.23. Patient records.

 (a)  A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.

 (b)  Each patient file shall include the following information:

   (1)  A complete personal history.

   (2)  A complete drug and alcohol history.

   (3)  A complete medical history.

   (4)  The results of an initial intake physical examination.

   (5)  The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.

   (6)  Results of laboratory tests or other special examinations given by the narcotic treatment program.

   (7)  Documentation of a 1-year history of narcotic dependency, if applicable.

   (8)  The patient’s current and past narcotic dosage level.

   (9)  Other drugs prescribed by the narcotic treatment physician and the reasons therefore.

   (10)  Urine testing results.

   (11)  Counselor notes regarding patient progress and status.

   (12)  Applicable consent forms.

   (13)  Patient record of services.

   (14)  Case consultation notes regarding the patient.

   (15)  Psychosocial evaluations of the patient.

   (16)  Any psychiatric, psychological or other evaluations, if available.

   (17)  Treatment plans and applicable periodic treatment plan updates.

   (18)  Federal and State exceptions to the regulations granted to the project on behalf of the patient.

   (19)  Referrals to other projects or services.

   (20)  Take-home privileges granted to the patient.

   (21)  Annual evaluation by the counselor.

   (22)  Aftercare plan, if applicable.

   (23)  Discharge summary.

   (24)  Follow-up information regarding the patient.

   (25)  Documentation of patient grievances.

 (c)  An annual evaluation of each patient’s status shall be completed by the patient’s counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient’s admission to a narcotic treatment program and shall address the following areas:

   (1)  Employment, education and training.

   (2)  Legal standing.

   (3)  Substance abuse.

   (4)  Financial management abilities.

   (5)  Physical and emotional health.

   (6)  Fulfillment of treatment objectives.

   (7)  Family and community supports.

 (d)  A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.

   (1)  The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.

   (2)  The narcotic treatment physician or the patient’s counselor shall review, reevaluate, modify and update each patient’s treatment plan as required by Chapters 709, 710 and 711 (relating to standards for licensure of freestanding treatment activities; drug and alcohol services; and standards for certification of treatment activities which are a part of a health care facility).

 (e)  Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.

 (f)  If a narcotic treatment program keeps patient information in more than one file or location, it is the responsibility of the narcotic treatment program to provide the entire patient record to authorized persons conducting narcotic treatment program approval activities at the narcotic treatment program, upon request.

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