Section 250.2860  Medical Records

a)         Each program shall maintain an organized record system for collection of information necessary to serve the client.

b)         All records shall be considered confidential and privileged.  A written policy and procedure shall be established detailing how confidentiality is maintained.

c)         The patient's comprehensive treatment plan must be recorded, based on an inventory of the patient's strengths as well as his disabilities, short-term and long range goals, and the specific treatment modalities utilized as well as the responsibilities of each member of the treatment team in such a manner that it provides adequate justification and documentation for the diagnoses and for the treatment and rehabilitation activities carried out.

d)         The treatment received by the patient must be documented in such a manner and with such frequency as to assure that all active therapeutic efforts such as individual and group therapy, drug therapy, occupational therapy, recreational therapy, medical and nursing care and other therapeutic interventions, such as voluntary self help groups, are included.

e)         Progress notes shall be recorded by the physician, clinical psychologist, alcoholism counselor, nurse, social worker and by others significantly involved in active treatment modalities.  The notes must contain recommendations for revisions in the treatment plan when indicated as well as precise assessment of the patient's progress in accordance with the original or revised treatment plan.

f)         The unique confidentiality requirements of the alcoholism patient's records shall be recognized and safeguarded in any unitized record keeping system of a general hospital.

g)         The discharge summary must include a recapitulation of the patient's hospitalization and recommendations from appropriate services concerning problems, plans for follow-up or after care as well as a brief summary of the patient's condition on discharge.

h)         All entries in the record shall be legible, dated and completed with the signature of the authorized individual providing the service and making the entry.  Signature stamps are prohibited.

i)          In the event the program is discontinued, the records shall be stored so that confidentiality and security is maintained.

(Source:  Added at 4 Ill. Reg. 25, p. 138, effective June 6, 1980)