Section 325.14927. Medical examination; substance abuse history; medical history; treatment of unconscious person and persons with severe medical complications prohibited; agreements with emergency medical departments; incapacitated persons; treatment plan for persons undergoing detoxification required; protective custody.

Rule 927. (1) A medical examination shall be performed  every  time  a person who is apparently incapacitated is brought to an approved service program, unless the individual has been transferred from an emergency medical service where  an examination was performed  and  documentation  of

the examination is available to the program.  If   the  examination   is performed at the approved service program, it shall be performed by a physician or his or her designee.

(2)    The medical examination  that   is  performed   upon  arrival  at   the approved service program shall include  an  examination for illness and injury.

(3)   Substance abuse history information shall be obtained as soon   after admission as is  practicable.  This  history  shall  include  all  of  the following:

(a)   Substances used in the past, including prescribed drugs.

(b)   Substances used recently, especially those used within the last 48 hours.

(c)   Substances of preference.

(d)  Frequency with which each substance is used.

(e)    Previous occurrences of overdose,    withdrawal,   or   adverse    drug   or alcohol reactions.

(f)  History of previous substance abuse treatment received.

(g)   Year of first use of each substance.

(4)   A complete medical history shall be obtained. The history shall contain all of the following information:

(a)   Head injuries.

(b)   Nervous diseases.

(c)   Convulsive diseases.

(d)  Major and minor operations.

(e)   Major accidents.

(f)  Fractures.

(g)   Venereal infections.

(h)   Cardiovascular diseases.

(i)   Respiratory diseases.

(j)   Endocrine diseases.

(k)   Rheumatic diseases.

(l)   Gastrointestinal diseases.

(m)   ) Allergic diseases.

(n)   Gynecological-obstetrical history, as appropriate.

(5)    An approved service program shall not treat unconscious persons or persons with severe medical complications. These persons shall be transported to the nearest hospital which is capable of providing the necessary services. This transportation plan shall be included in the written triage process.

(6)     Approved service programs shall have written agreements with emergency medical departments to provide services beyond the medical capacity of approved service programs.

(7)   An approved service program shall have a written description of its procedures for a medical evaluation. This description shall be approved by the program physician.

(8)   If an individual in an incapacitated condition is to be admitted to an approved service program, there shall be documentation in his or her medical exam  records which explicitly attests to the individual's incapacitated condition. The basis of the decision, including blood alcohol level, if taken, shall be specified.

(9)    If an individual is found not to be incapacitated, the approved service program medical records shall so state. An individual found not to be incapacitated cannot be held in protective custody,  but  may   be voluntarily admitted for residential care services.

(10)   Approved service programs shall have a written description of the protocol for treatment of incapacitated individuals. This protocol shall be approved by the program physician.

(11)   There shall be a treatment plan for  each   client who  undergoes detoxification at an approved service program. A standard of care procedure specifying an appropriate treatment regimen may be utilized. The treatment plan shall include all of the following:

(a)   Those services necessary to meet the client's medical needs.

(b)   Referrals to be made for medical and nursing services which are not provided by the program.

(c)     Documentation that the treatment plan has been periodically evaluated and updated.

(12)   The approved service program shall not keep an individual in protective custody more than 72 hours. If the  physician  deems  it appropriate, an individual may voluntarily remain in the approved service program for more than 72 hours. The physician shall document the need for additional approved service program services beyond 72 hours in the client's medical records. The physician shall also enter documentation of the need for additional services in the medical records for each 24- hour period beyond 72 hours.

History: 1981 AACS.