Authority: IC 12-23-1-6; IC 12-23-18

Affected: IC 12-23-18; IC 16-39-7-1

Sec. 9. (a) An OTP shall maintain a master patient record for each current patient at the OTP medication administering site.

(b) If any OTP patient services are provided at a certified addiction treatment facility, the OTP shall have written policies and procedures requiring the inclusion of, and time frame for inclusion of, copies of all chart notes and records of patient services in the master patient record at the OTP medication administering site.

(c) The content and format of patient records shall be uniform. Entries shall be signed and dated by the staff member making the entry.

(d) Patient records shall be:

1. (1) kept confidential; and

2. (2) protected against:

   1. (A) loss;
   2. (B) tampering; or
   3. (C) unauthorized disclosure.

(e) Records of discharged patients shall be retained for a period of at least seven (7) years after the patient's last contact with the OTP.

(f) An OTP that ceases to provide treatment services shall do the following:

1. (1) Retain patient records for at least seven (7) years from the date of facility closure.

2. (2) Notify the division of the following:

   1. (A) The location of the records.
   2. (B) The name of the person responsible for maintaining the records.

(g) An OTP shall establish a written record for each patient to include at least the following:

1. (1) The patient's written informed consent to treatment.

2. (2) Documentation showing that the patient was given information on the following:

   1. (A) Patient rights, including the right to confidentiality.
   2. (B) Patient responsibilities.
   3. (C) The OTP's grievance procedures.
3. (3) Medication dose history, including current dose.
4. (4) Results of medical tests, including drug testing.
5. (5) The current treatment plan.
6. (6) Progress addressing treatment plan goals.
7. (7) Documentation of each contact with the patient and patient's family.
8. (8) Referrals to services not provided by the OTP.

(h) The OTP shall make all patient information contained in patient records available to the division and its agents upon request.

(Division of Mental Health and Addiction; 440 IAC 10-4-9; filed Dec 30, 2009, 2:00 p.m.: 20100127-IR- 440080412FRA; readopted filed May 10, 2016, 11:24 a.m.: 20160608-IR-440160134RFA; readopted filed Nov 9, 2022, 4:31 p.m.: 20221207-IR-440220292RFA)