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(1) A specialty mental health facility must maintain a medical records system in accordance with written policies and procedures, as well as meet the following standards:

(a) Employ adequate personnel to ensure prompt and systematic completion, filing, and retrieval of records.

(b) Create and maintain a record for each person receiving specialty mental health care services from the facility that includes, if applicable:

(i) identification and social data;

(ii) admitting diagnosis;

(iii) pertinent medical history;

(iv) properly executed consent forms;

(v) reports of physical examinations, diagnostic and laboratory test results, and consultation findings;

(vi) all physician's orders, nurses' notes, and reports of treatments and medications;

(vii) final diagnosis;

(viii) discharge summary; and

(ix) any other pertinent information necessary to monitor the patient's prognosis.

(c) Include in each record the signatures of the physician or other health care professional authoring the record entries.

(d) Complete records of a discharged patient within 30 days after the discharge date and include, in addition to the information cited in (b) above, a recapitulation of the patient's period of treatment, a recommendation of the appropriate follow up or aftercare services for the patient, and a brief summary of the patient's medical and mental condition on discharge.

(e) Have written policies and procedures ensuring the confidentiality of patient records, and safeguards against loss, destruction or unauthorized use, in accordance with applicable state and federal law and including policies and procedures which:

(i) govern the use and removal of records from the record storage area;

(ii) specify the conditions under which information may be released and by whom;

(iii) specify when the patient's consent is required for release of information, in accordance with Title 50, chapter 16, part 5, MCA, the Uniform Health Care Information Act.

(f) In addition to the above, adhere to the provisions of ARM 37.106.314.

(2) The department hereby adopts and incorporates by reference ARM 37.106.314, which contains medical records requirements for types of health care facilities other than hospitals. Copies may be obtained from the Department of Public Health and Human Services, Quality Assurance Division, 2401 Colonial Drive, P.O. Box 202953, Helena, MT 59620-2953.

History: Sec. 50-5-103, MCA; IMP, Sec. 50-5-103, MCA; NEW, 1991 MAR p. 2454, Eff. 12/13/91; TRANS, from DHES, 2002 MAR p. 185.

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