(1) The service provider must ensure client record content includes:

(a) demographic information;

(b) a substance related disorder diagnosis and supporting documentation for diagnosis;

(c) biopsychosocial assessment including diagnosis showing the rationale for admission;

(d) documentation the client was informed of federal confidentiality requirements and received a copy of the client notice;

(e) assurance all clients have an orientation to the program's treatment services, infectious disease information, and disaster plan;

(f) voluntary consent to treatment signed and dated by the client or legal guardian;

(g) treatment plan;

(h) progress notes;

(i) discharge summary;

(j) medication records, if applicable;

(k) laboratory reports, if applicable;

(l) properly completed authorizations for release of information;

(m) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and

(n) documentation showing client received a copy of client grievance policies and procedures.

History: 50-5-103, 53-24-208, MCA; IMP, 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA; NEW, 2010 MAR p. 2975, Eff. 12/24/10.