Sec. 819.5. Recordkeeping

(a) Chemical dependence residential services must maintain individual case records for each resident served. These records must, at a minimum, include the information required in this Part, as well as the source of referral, documentation of any case conferences or case reviews, reports of other evaluations and case consultations, medical orders, if applicable, and consent forms.

(b) Resident records maintained by chemical dependence residential services are confidential and may only be disclosed in conformity with Federal regulations relating to the confidentiality of records as set forth in 42 Code of Federal Regulations part 2 and other applicable law.

(c) Any medical procedures required, including use of any medication, shall be maintained in accord with the requirements of Federal and State law and approved policies and procedures.

(d) All medical services provided must be provided pursuant to physician's, physician assistant's, or nurse practitioner's order.

(e) In the event that more than one chemical dependence service is offered by a facility, the resident record shall identify the service in which the resident is currently participating.

(f) Statistical information shall be reported to the office as required and on the prescribed forms therefor.