Section 388-877B-0120. Substance use disorder detoxification services—Clinical record content and documentation requirements.

In addition to the general clinical record content requirements in WAC 388-877-0640, an agency providing substance use disorder detoxification services must maintain an individual's clinical record that contains:

(1) Documentation of a substance use disorder screening before admission.

(2) A voluntary consent to treatment form, or any release forms, signed and dated by the individual, or the individual's parent or legal guardian, except as authorized by law for protective custody and involuntary treatment.

(3) Documentation that the individual was informed of federal confidentiality requirements and received a copy of the individual notice required under 42 C.F.R., Part 2.

(4) Documentation that the individual received the HIV/AIDS brief risk intervention.

(5) Documentation of progress notes in a timely manner from each shift and as events occur, or documentation as to why this did not occur. Progress notes must include the date, time, duration, participant names, and a brief summary of the shift or event, and the name of the staff member who provided it.

(6) Documentation that a discharge summary, including a continuing care recommendation and a description of the individual's physical condition, was completed within seven working days of discharge.

[Statutory Authority: RCW 70.02.290, 70.02.340, 70.96A.040(4), 71.05.560, 71.24.035 (5)(c), 71.34.380, and 2014 c 225. WSR 16-13-087, § 388-877B-0120, filed 6/15/16, effective 7/16/16. Statutory Authority: Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877B-0120, filed 5/31/13, effective 7/1/13.]

RCW 70.02.290, 70.02.340, 70.96A.040(4), 71.05.560, 71.24.035 (5)(c), 71.34.380, and 2014 c 225. WSR 16-13-087, § 388-877B-0120, filed 6/15/16, effective 7/16/16. Statutory Authority: Chapters 70.02, 70.96A, 71.05, 71.24, 71.34, 74.50 RCW, RCW 74.08.090, 43.20A.890, and 42 C.F.R. Part 8. WSR 13-12-053, § 388-877B-0120, filed 5/31/13, effective 7/1/13.

Rules

388-877-0640,