Subdivision 1. Patient records required. A license holder must maintain a file of current patient records on the program premises where the treatment is provided. Each entry in each patient record must be signed and dated by the staff member making the entry. Patient records must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and section 254A.09; Code of Federal Regulations, title 42, sections 2.1 to 2.67; and title 45, parts 160 to 164.
Subd. 2. Records retention. A license holder must retain and store records as required by section 245A.041, subdivisions 3 and 4.
Subd. 3. Contents of records. Patient records must include the following:
(1) documentation of the patient's presenting problem, any substance use screening, the most recent assessment, and any updates;
(2) a stabilization plan and progress notes as required by section 245F.07, subdivisions 1 and 2;
(3) a discharge summary as required by section 245F.07, subdivision 3;
(4) an individual abuse prevention plan that complies with section 245A.65 and related rules;
(5) documentation of referrals made; and
(6) documentation of the monitoring and observations of the patient's medical needs.
2015 c 71 art 3 s 19
Structure Minnesota Statutes
Chapters 245 - 267 — Public Welfare And Related Activities
Chapter 245F — Withdrawal Management Programs
Section 245F.02 — Definitions.
Section 245F.03 — Application.
Section 245F.04 — Program Licensure.
Section 245F.05 — Admission And Discharge Policies.
Section 245F.06 — Screening And Comprehensive Assessment.
Section 245F.07 — Stabilization Planning.
Section 245F.08 — Stabilization Services.
Section 245F.09 — Protective Procedures.
Section 245F.10 — Patient Rights And Grievance Procedures.
Section 245F.11 — Patient Property Management.
Section 245F.12 — Medical Services.
Section 245F.13 — Medications.
Section 245F.14 — Staffing Requirements And Duties.
Section 245F.15 — Staff Qualifications.
Section 245F.16 — Personnel Policies And Procedures.
Section 245F.17 — Personnel Files.
Section 245F.18 — Policy And Procedures Manual.
Section 245F.19 — Patient Records.