1. (1) The substance use disorder residential facility (SUDF) must develop and implement procedures to ensure each client record is available on-site and includes:

   1. (a) demographic information;
   2. (b) a substance related disorder diagnosis and supporting documentation for diagnosis;
   3. (c) biopsychosocial assessment including diagnosis showing the rationale for admission;
   4. (d) signed documentation the client was informed of federal confidentiality requirements and received a copy of the client notice as required in ARM 37.106.1416;
   5. (e) signed documentation the client received orientation to the SUDF's treatment services, infectious disease information, and disaster plan described in ARM 37.106.322;
   6. (f) a voluntary consent to treatment signed and dated by the client or legal guardian;
   7. (g) individualized treatment plan and treatment plan reviews;
   8. (h) progress notes;
   9. (i) clinical notes;
   10. (j) continuing care plan;
   11. (k) medication records, if applicable;
   12. (l) laboratory reports, if applicable;
   13. (m) authorizations for release of information, as needed;
   14. (n) copies of all correspondence related to the client, including any court orders and reports of noncompliance; and
   15. (o) documentation pertaining to client receipt of grievance policies and procedures.
   16. (p) documentation of any client-filed written grievances and resolution;
   17. (q) documentation the client received a copy of the client rights policy and the client's signature indicating he/she received the policy; and
   18. (r) documentation of school educational courses attended or provided.

Authorizing statute(s): 50-5-103, 53-24-208, MCA

Implementing statute(s): 50-5-101, 50-5-103, 53-24-208, 53-24-209, 76-2-411, MCA

History: NEW, 2010 MAR p. 2975, Eff. 12/24/10; AMD, 2022 MAR p. 2040, Eff. 9/24/22.