Section 325.14419. Client records.

(1) A client record shall be maintained by a program for a period of 3 years after services are terminated.

(2)   A client record shall contain, at a minimum, all  of the following information:

(a)   A signed consent form (use federal food and drug administration form FD 2635).

(b)   The date of each visit for medication or counseling, or both.

(c)   The amount of methadone dispensed for take-out or administered on-site.

(d)  The results of each urinalysis.

(e)   A detailed account of any adverse reactions to medication (use  federal food and drug administration form 1639, "Drug Experience Report").

(f)   Any significant physical or  psychological  disability   and  plans  for referral or on-site treatment.

(g)   If the client's treatment plan identifies a need for counseling services and includes the provision of these services, then signed and dated progress reports by the counselor must be included in the clinical record.

(h)   The termination and readmission   evaluation  written   or  endorsed  and dated by the program physician.

(i)   Monthly medical progress notes by the dispensing nurse.

(j)   Monthly renewal of the methadone order.

(k)   Documentation of a physician-client encounter every 60 days.

(l)      Documentation  of  methadone  authority  approval  of   any  exceptions  to   the applicable rules and regulations.

(m)   ) The initial, and any subsequent, treatment plan.

(n)   The periodic treatment plan evaluation  by   the  program  physician  or counselor at least once every 60 days.

(o)   The annual treatment plan review by the program physician.

(3)    Deaths which may be methadone related shall be reported to the federal food and drug administration on form FD 1639, "Drug Experience Report" within 2 weeks of the death. Births to clients that are premature or show signs of adverse reaction to methadone shall also be reported on form FD 1639.

History: 1981 AACS; 2006 AACS.