<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".08" citation="COMAR 10.47.01.08" title_num="10" subtitle_num="47" chapter_num="01" heading="Records.">
  <paragraph num="A.">
    <text>Program Records.</text>
    <paragraph num="(1)">
      <text>A program shall either manually or electronically maintain a record for each patient that includes, but is not limited to:</text>
      <paragraph num="(a)">
        <text>A patient identifier, which may be a name, number, or an identifying code;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Intake information, including the patient's name, date of admission, summary of medical examinations, allergies to medication, and laboratory reports;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Assessments, individualized treatment plans, progress notes, and consent to disclose information if needed;</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Documentation of each program contact with the patient;</text>
      </paragraph>
      <paragraph num="(e)">
        <text>Critical incident reports documented on the day of the incident; and</text>
      </paragraph>
      <paragraph num="(f)">
        <text>A discharge summary.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(2)">
      <text>A program shall maintain Medicaid patient records for at least 6 years following discharge, and all other patient records for at least 3 years as required by Health-General Article, §4-403, Annotated Code of Maryland, and shall:</text>
      <paragraph num="(a)">
        <text>Maintain, transfer, and destroy all records in a manner consistent with the medical records confidentiality and disclosure requirements of:</text>
        <paragraph num="(i)">
          <text>Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>Health-General Article, §4-403, Annotated Code of Maryland;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>42 CFR Part 2;</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>The Health Insurance Portability and Accountability Act (HIPAA); and</text>
        </paragraph>
        <paragraph num="(v)">
          <text>45 CFR Parts 160 and 164;</text>
        </paragraph>
      </paragraph>
      <paragraph num="(b)">
        <text>Locate all records so that they are convenient and available to designated staff; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Provide a designated staff member responsible for appropriate records control, including storage, security, and indexing records.</text>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>Management Information System. The program shall:</text>
    <paragraph num="(1)">
      <text>Participate in the Administration's management information system;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Comply with reporting requirements as required by the Department; and</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Complete and submit the driving while intoxicated data collection form chosen by the Administration for those arrested for driving while intoxicated or driving under the influence.</text>
    </paragraph>
  </paragraph>
  <paragraph num="C.">
    <text>Electronic Records.</text>
    <paragraph num="(1)">
      <text>Electronic records shall be maintained according to requirements set forth in this regulation.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>A companion hard copy file shall be maintained at the program and shall contain the following:</text>
      <paragraph num="(a)">
        <text>Informed consent to treatment signed by the patient;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Any requests for or releases of information shared with other entities signed by the patient;</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Any treatment plan or treatment plan update signed by the patient; and</text>
      </paragraph>
      <paragraph num="(d)">
        <text>Any program agreements or patient/counselor behavioral contracts signed by the patient.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>