This regulation specifies the minimum required contents of client records for substance use disorder (SUD) service providers licensed under DC's behavioral health regulations. Operators must maintain documentation covering intake screening, consent, rights notices, assessments, treatment plans, encounter notes (with detailed billing support requirements), medication records, drug test results, referrals, and discharge summaries. The record-keeping requirements apply across the levels of care governed by this chapter of the DC Department of Behavioral Health SUD licensing rules.
View official sourceCLIENT RECORD CONTENTS At a minimum, all client records shall include: Documentation of the referral and initial screening interview and its findings; The client’s consent to SUD services; The Client’s Rights Statement; Documentation that the client received: An orientation to the program’s services, rules, confidentiality practices, and client’s rights; and Notice of privacy practices and opt-out forms. Confidentiality forms and releases signed to permit the facility to obtain and/or release information; Diagnostic interview and assessment record, including any Department-approved screening and assessment tools; Evaluation of medical needs and, as applicable, medication intake sheets and special diets which shall include: Documentation of physician’s orders for medication and treatment, change of orders, and/or special treatment evaluation; For drugs prescribed following admissions, any prescribed drug product by name, dosage, and strength, as well as date(s) medication was administered, discontinued, or changed; and For any prescribed “OTC” medications following admissions, any OTCs by product name, dosage, and strength, as well as date(s) medication was administered, discontinued, or changed. Assessments and individual treatment plans pursuant to the LOC and the client’s needs, including recovery plans, if applicable; Encounter notes, which provide sufficient written documentation to support each therapy, service, activity, or session for which billing is made that, at a minimum, consists of: The specific service type rendered; Dated and authenticated entries with their authors identified, that include the duration, and actual time (beginning and ending as well as a.m. or p.m.), during which the services were rendered. To constitute a valid signature, digital signatures must include a date and time stamp contemporaneous with the signature function and must be recorded and readily retrievable in the electronic system’s audit log; Name, title, and credentials (if applicable) of the person providing the services; The setting in which the services were rendered; Confirmation that the services delivered are contained in the client’s treatment or recovery plan and are identified in the encounter note; A description of each encounter or intervention provided to the client, which is sufficient to document that the service was provided in accordance with this chapter; A description of the client’s response to the intervention sufficient to show, particularly in the case of group interventions, their unique participation in the service; and Provider’s observations. Documentation of all services provided to the client as well as activities directly related to the individual treatment or recovery plan that are not included in encounter notes; Documentation of missed appointments and efforts to contact and reengage the client; Documentation of any personal articles of the client held by the provider for safekeeping and any statements acknowledging receipt of the property; Emergency contact information of individuals to contact in case of a client emergency with appropriate consent to share information; Documentation of all referrals to other agencies and the outcome of such referrals; Documentation establishing all attempts to acquire necessary and relevant information from other sources; Pertinent information reported by the client, family members, or significant others regarding a change in the client’s condition and/or an unusual or unexpected occurrence in the client’s life; Drug test results and incidents of drug use; Discharge summary and aftercare plan; Outcomes of care and follow-up data concerning outcomes of care; Documentation of correspondence including with other medical, community providers, human service, social service, and criminal justice entities as it pertains to a client’s treatment and/or recovery; and Documentation of a client’s representative payee or legal guardian, as applicable. SOURCE: Final Rulemaking published at 62 DCR 12056 (September 4, 2015); as amended by Final Rulemaking published at 67 DCR 011585 (October 9, 2020). District of Columbia Municipal Regulations Mental Health 22-A DCMR § 6324