53-21-165. Records to be maintained. Complete patient records must be kept by the mental health facility for the length of time required by rules established by the department. All records kept by the mental health facility must be available to any person authorized by the patient in writing to receive these records and upon approval of the authorization by the board. The records must also be made available to any attorney charged with representing the patient or any professional person charged with evaluating or treating the patient. These records must include:

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(1)identification data, including the patient’s legal status;

(2)a patient history, including but not limited to:

(a)family data, educational background, and employment record;

(b)prior medical history, both physical and mental, including prior hospitalization;

(3)the chief complaints of the patient and the chief complaints of others regarding the patient;

(4)an evaluation that notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the patient’s assets in descriptive rather than interpretative fashion;

(5)a summary of each physical examination that describes the results of the examination;

(6)a copy of the individual treatment plan and any modifications to the plan;

(7)a detailed summary of the findings made by the reviewing professional person after each periodic review of the treatment plan, required under 53-21-162(4), that analyzes the successes and failures of the treatment program and includes recommendations for appropriate modification of the treatment plan;

(8)a copy of the individualized discharge plan and any modifications to the plan and a summary of the steps that have been taken to implement that plan;

(9)a medication history and status that includes the signed orders of the prescribing physician or advanced practice registered nurse. The staff person administering the medication shall indicate by signature that orders have been carried out.

(10)a summary of each significant contact by a professional person with the patient;

(11)documentation of the implementation of the treatment plan;

(12)documentation of all treatment provided to the patient;

(13)chronological documentation of the patient’s clinical course;

(14)descriptions of any changes in the patient’s condition;

(15)a signed order by a professional person for any restrictions on visitations and communications;

(16)a signed order by a professional person for any physical restraints and isolation;

(17)a detailed summary of any extraordinary incident in the facility involving the patient, to be entered by a staff member noting that the staff member has personal knowledge of the incident or specifying any other source of information. The summary of the incident must be initialed within 24 hours by a professional person.

(18)a summary by the professional person in charge of the facility or by an appointed agent of the determination made after the 30-day review provided for in 53-21-163.