37.106.1909    MENTAL HEALTH CENTER: CLINICAL RECORDS

(1) Each mental health center shall:

(a) collect assessment data and maintain clinical records on all clients who receive services and ensure the confidentiality of clinical records in accordance with the Uniform Health Care Information Act, Title 50, chapter 16, part 5, MCA. At a minimum, the clinical record must include:

(i) a clinical intake assessment;

(ii) additional assessments or evaluations, if clinically indicated;

(iii) a copy of the client's individualized treatment plan and all modifications to the treatment plan;

(iv) progress notes which indicate whether or not the stated treatment plan has been implemented, and the degree to which the client is progressing, or failing to progress, toward stated treatment objectives;

(v) medication orders from the prescribing physician and documentation of the administration of all medications;

(vi) signed orders by a licensed mental health professional for any restrictions of rights and privileges accorded clients of the mental health center including the reason(s) for the restriction; and

(vii) a discharge summary when the client's file is closed.

History: 50-5-103, MCA; IMP, 50-5-103, 50-5-204, MCA; NEW, 1998 MAR p. 539, Eff. 2/27/98; TRANS & AMD, 2002 MAR p. 916, Eff. 3/29/02.