N.M. Admin. Code § 8.321.11.28 - CLIENT CLINICAL RECORD
The client clinical records maintained by a crisis triage center in a paper-based or electronic system shall document the degree and intensity of the treatment provided to clients who are furnished services by the CTC. A client's clinical record shall contain at a minimum:
A. the client's name and address;
B. name, address, and telephone number of
agent, or representatives;
C. the
source of referral and relevant referral information;
D. all reports from client assessment (see
program services assessment);
E.
the signed and dated informed consent for treatment including all medications
and transfers;
F. all additional
medical and clinical documentation;
G. the original crisis stabilization plan and
all revisions;
H. documentation of
all treatment;
I. laboratory and
radiology results, if applicable;
J. documentation of physical restraint
observations, if utilized;
K. a
record of all contacts with medical and other services;
L. a record of medical treatment and
administration of medication, if administered;
M. an original or original copy of all
physician medication and treatment orders signed by the physician;
N. signed consent for the release of
information, if information is released;
O. discharge plan.
Notes
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No prior version found.