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(Effective until May 1, 2023)

PDFWAC 246-341-1015

Opioid treatment programs (OTP)Clinical record content and documentation requirements.

An agency providing opioid treatment program services must maintain an individual's clinical record. The clinical record must contain:
(1) Documentation that the agency made a good faith effort to review if the individual is enrolled in any other opioid treatment program and take appropriate action;
(2) Documentation that the individual received a copy of the rules and responsibilities for treatment participants, including the potential use of interventions or sanction;
(3) Documentation that the individual service plan was reviewed quarterly and semi-annually after two years of continuous treatment;
(4) Documentation when an individual refuses to provide a drug testing specimen sample. The refusal is considered a positive drug screen specimen;
(5) Documentation in progress notes of timely interventions used to therapeutically address the disclosure of illicit drug use, a positive drug test, or possible diversion of opioid medication, as evidenced by the absence of opioids or related metabolites in drug toxicology test results;
(6) Documentation of all medical services including:
(a) Results of physical examination;
(b) Medical and family history;
(c) Nursing notes;
(d) Laboratory reports including results of regular toxicology screens, a problem list, and list of medications updated as clinically indicated; and
(e) Progress notes including documentation of all medications and dosages, if available.
[Statutory Authority: RCW 71.24.037, 71.05.560, 71.34.380, 18.205.160, 71.24.037 and chapters 71.05, 71.24, and 71.34 RCW. WSR 21-12-042, § 246-341-1015, filed 5/25/21, effective 7/1/21. Statutory Authority: 2018 c 201 and 2018 c 291. WSR 19-09-062, § 246-341-1015, filed 4/16/19, effective 5/17/19.]
(Effective May 1, 2023)

PDFWAC 246-341-1015

Opioid treatment programs (OTP)Individual service record content and documentation requirements.

An agency providing opioid treatment program services must maintain an individual's individual service record. The individual service record must contain:
(1) Documentation that the agency made a good faith effort to review if the individual is enrolled in any other opioid treatment program and take appropriate action;
(2) Documentation that the individual received a copy of the rules and responsibilities for treatment participants, including the potential use of interventions or sanction;
(3) Documentation that the individual service plan was reviewed quarterly and semi-annually after two years of continuous treatment;
(4) Documentation when an individual refuses to provide a drug testing specimen sample. The refusal is considered a positive drug screen specimen;
(5) Documentation in progress notes of timely interventions used to therapeutically address the disclosure of illicit drug use, a positive drug test, or possible diversion of opioid medication, as evidenced by the absence of opioids or related metabolites in drug toxicology test results;
(6) Documentation of all medical services including:
(a) Results of physical examination;
(b) Medical and family history;
(c) Nursing notes;
(d) Laboratory reports including results of regular toxicology screens, a problem list, and list of medications updated as clinically indicated; and
(e) Progress notes including documentation of all medications and dosages, if available.
[Statutory Authority: RCW 71.24.037, 71.05.560, 71.34.380, 18.205.160, 43.70.080(5), 41.05.750, 43.70.250, and 74.09.520 and chapters 71.05, 71.12, 71.24 and 71.34 RCW. WSR 22-24-091, § 246-341-1015, filed 12/6/22, effective 5/1/23. Statutory Authority: RCW 71.24.037, 71.05.560, 71.34.380, 18.205.160, 71.24.037 and chapters 71.05, 71.24, and 71.34 RCW. WSR 21-12-042, § 246-341-1015, filed 5/25/21, effective 7/1/21. Statutory Authority: 2018 c 201 and 2018 c 291. WSR 19-09-062, § 246-341-1015, filed 4/16/19, effective 5/17/19.]
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