37.106.2109    CLIENT RECORDS

(1) The facility must develop and maintain a recordkeeping system that includes a separate record for each client and that documents the client's health care, treatment and habilitation, including preliminary evaluation, comprehensive functional assessments, individual treatment plan, progress notes, social information, and protection of the client's rights.

(2) The facility must keep confidential all information contained in the client's records, regardless of the form or storage method of the records.

(3) The facility must develop and implement policies and procedures governing the release of any client information, including consents necessary from the client or legal guardian.

(4) Any individual who makes an entry in a client's record must make it legibly, date it, and sign it.

(5) The facility must provide a legend to explain any symbol or abbreviation used in a client's record.

(6) The facility must provide each identified residential living unit with appropriate aspects of each client's record.

History: Sec. 50-5-103 and 50-5-238, MCA; IMP, Sec. 53-5-103, 50-5-201 and 50-5-238, MCA; NEW, 2003 MAR p. 1322, Eff. 7/1/03.