Minnesota Administrative Rules

9515.3110 RECORDS OF PERSONS IN TREATMENT.

Subpart 1.

Central record file on premises.

The license holder must maintain a central file of persons' records on the program premises.

Subp. 2.

Admission record.

Each person's admission record must include:

A.

the person's name, date of birth, and social security number;

B.

a photograph taken at admission;

C.

the date of admission;

D.

the name, address, and telephone number of an individual to contact in case of an emergency;

E.

documentation that the person's legal or medical status meets admission criteria;

F.

names of victims identified as requiring or requesting protection from the person or notification of the person's release or change of status; and

G.

names and telephone numbers of the person's attorney, county case manager, and any other individual warranted by the person's legal or medical status.

Subp. 3.

Treatment records.

The license holder must document the course of evaluation and treatment for each person in treatment. In addition to any other documentation the license holder chooses to include, each persons's record must contain:

A.

copies of the person's diagnostic assessment, individual treatment plan, progress notes, quarterly evaluation, and discharge plan;

B.

names of the person's medical providers;

C.

documentation of incidents or emergencies involving the person;

D.

copies of any State Review Board reports on the person; and

E.

a copy of the person's transfer and discharge summary when applicable.

Subp. 4.

Consent to release information in record.

The license holder shall not release information in a persons's record without a written consent signed by the person that specifies:

A.

the date of authorization and length of time, not to exceed six months from the date of the persons's signature, for which the consent is valid;

B.

the information that will be released;

C.

the purpose for releasing the information; and

D.

the name of the individual or organization authorized to receive the information.

Subp. 5.

Secure confidential file.

Confidential information that is not to be released to a person must be kept separate from the person's medical record in a secure confidential file. The file must be accessible to staff 24 hours a day.

Statutory Authority:

MS s 246B.04

History:

20 SR 935

Published Electronically:

February 2, 2005