Utah Admin. Code R501-1-11 - Program Client Record Requirements

(1) The licensee shall maintain client information to include the following:

(a) client name, address, email address, phone number, date of birth and identified gender;

(b) emergency contact names, including legal guardian where applicable, and at minimum, the emergency contact's physical address, current email address or current phone numbers;

(c) a program serving substance use disorder clients shall maintain compliance with an initial and annual client tuberculosis screening results in each client record;

(d) any information that could affect health safety or well-being of the client including each medication, allergy, chronic condition or communicable disease;

(e) intake screening and assessment;

(f) discharge documentation;

(g) treatment or service plan;

(h) progress notes and services provided with date and signature of staff completing each entry;

(i) individualized assessment for restriction of access to on-site items that could be used as weapons, for self-directed violence, or as an intoxicant;

(j) any referral arrangements made by the program;

(k) client or guardian signed consent or court order of commitment to services in lieu of signed consent for each treatment and non-clinical service;

(l) summary of attendance and absences in treatment services;

(m) any grievance or complaint made by or against the client and actions taken by the program;

(n) each crisis intervention or critical incident report involving the client; and

(o) any signed agreement and consent form.

(2) The licensee shall document a plan detailing how each program staff and client file is maintained and remains available to the office and other agencies legally authorized to access the files for seven years regardless of whether the program remains licensed.

Notes

Utah Admin. Code R501-1-11

Adopted by Utah State Bulletin Number 2017-3, effective 1/17/2017 Amended by Utah State Bulletin Number 2018-6, effective 2/23/2018 Amended by Utah State Bulletin Number 2019-4, effective 1/17/2019 Amended by Utah State Bulletin Number 2022-02, effective 1/6/2022 Amended by Utah State Bulletin Number 2022-08, effective 4/5/2022 Amended by Utah State Bulletin Number 2023-06, effective 3/2/2023 Adopted by Utah State Bulletin Number 2024-01, effective 12/19/2023