10.47.01.08

.08 Records.

A. Program Records.

(1) A program shall either manually or electronically maintain a record for each patient that includes, but is not limited to:

(a) A patient identifier, which may be a name, number, or an identifying code;

(b) Intake information, including the patient's name, date of admission, summary of medical examinations, allergies to medication, and laboratory reports;

(c) Assessments, individualized treatment plans, progress notes, and consent to disclose information if needed;

(d) Documentation of each program contact with the patient;

(e) Critical incident reports documented on the day of the incident; and

(f) A discharge summary.

(2) A program shall maintain Medicaid patient records for at least 6 years following discharge, and all other patient records for at least 3 years as required by Health-General Article, §4-403, Annotated Code of Maryland, and shall:

(a) Maintain, transfer, and destroy all records in a manner consistent with the medical records confidentiality and disclosure requirements of:

(i) Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland;

(ii) Health-General Article, §4-403, Annotated Code of Maryland;

(iii) 42 CFR Part 2;

(iv) The Health Insurance Portability and Accountability Act (HIPAA); and

(v) 45 CFR Parts 160 and 164;

(b) Locate all records so that they are convenient and available to designated staff; and

(c) Provide a designated staff member responsible for appropriate records control, including storage, security, and indexing records.

B. Management Information System. The program shall:

(1) Participate in the Administration's management information system;

(2) Comply with reporting requirements as required by the Department; and

(3) Complete and submit the driving while intoxicated data collection form chosen by the Administration for those arrested for driving while intoxicated or driving under the influence.

C. Electronic Records.

(1) Electronic records shall be maintained according to requirements set forth in this regulation.

(2) A companion hard copy file shall be maintained at the program and shall contain the following:

(a) Informed consent to treatment signed by the patient;

(b) Any requests for or releases of information shared with other entities signed by the patient;

(c) Any treatment plan or treatment plan update signed by the patient; and

(d) Any program agreements or patient/counselor behavioral contracts signed by the patient.