048-2 Wyo. Code R. §§ 2-11 - [Effective 9/26/2024] Client Case Records
(a) A provider shall maintain a client case
record for each client admitted for services.
(b) A provider shall maintain all client case
records in accordance with professional standards of practice, including
storage of records in a secure and designated area.
(c) Client case records must include the
following documentation and reflect the following applicable services utilizing
ASAM criteria, according to the unique needs of each individual client:
(i) Consent to receive treatment signed by
the client or legal guardian;
(ii)
A statement signed by the client or legal guardian affirming that
confidentiality was explained to them and that they understand what information
is protected and under what circumstances information can or cannot be
released;
(iii) A form signed by
the client or legal guardian acknowledging receipt and affirming that they
understand the procedures for filing a complaint;
(iv) A form signed within the last year by
the client or legal guardian acknowledging receipt and affirming that they
understand client rights;
(v) A
form signed by the client or legal guardian acknowledging receipt,
understanding, and acceptance of provider policies and procedures governing the
treatment process;
(vi) Clinical
assessments, based on the following criteria:
(A) A provider serving adults shall utilize
an evidence-based assessment tool which includes comprehensive information
regarding the client's bio-psychosocial and spiritual needs;
(B) A provider serving adolescents shall
utilize a bio-psychosocial assessment tool which, at a minimum, includes the
following domains: medical, criminal, substance use, family, psychiatric,
developmental and academic history; intellectual capacity; physical and sexual
abuse history; spiritual needs; peer, environmental, and cultural history; and,
assessment of suicidal and homicidal ideation;
(C) A provider shall utilize the ASAM
criteria including the dimensional criteria for each domain in the assessment
process;
(D) A provider shall
adequately assess the client's need for case management services according to
subsection (ix) of this section; and
(E) When a client is transferred from another
provider which completed the assessment, a receiving provider shall complete a
transfer note showing that the assessment information was reviewed. Further, a
provider shall determine if the client's needs are congruent with this
assessment, make needed adjustments to treatment recommendations, and note the
adjustment in the client file;
(vii) Diagnosis and diagnostic summary
utilizing diagnostic tools which are standard for the field and which are
acknowledged by the Department and payer sources;
(viii) Treatment plans, which must:
(A) Be completed when treatment is initiated
and updated at a minimum of every ninety (90) calendar days;
(B) Be developed utilizing the assessment
information, including the diagnosis and ASAM criteria;
(C) Integrate mental health needs if included
as part of the assessment and diagnosis, if identified as part of the
assessment process, or at any point during the course of treatment;
and
(D) Include:
(I) Evidence the client or guardian
participated in the development of the treatment plan, signed the treatment
plan, and received a copy of the treatment plan;
(II) Outcome driven goals and measurable
objectives;
(III) Changes in the
client's symptoms and behaviors that are expected during the course of
treatment in the current level of service, expressed in measurable and
understandable terms;
(IV) The
desired improved functioning level of the client utilizing the assessment;
and
(V) Documentation of
appropriate consequences of infractions that do not require immediate
termination with appropriate timeframes for clients to address infractions
prior to terminating the client;
(ix) A case management plan, based on the
following criteria;
(A) A provider shall
provide case management services directly or through memorandum of agreement
among multiple agencies or providers;
(B) Case management services must include
collaboration with other available agencies, providers, and services to meet
individual client needs based on ongoing assessments when applicable;
and
(C) Special emphasis must be
placed on coordinating with other providers including, but not limited to,
education institutions, vocational rehabilitation, recovery supports, and
workforce development services to enhance the client's skill base, chances for
gainful employment, housing, community resource supports, and other options for
independent functioning;
(x) Progress notes, which must:
(A) Document the symptoms and condition of
the client, response to treatment, and progress or lack of progress toward
specified treatment goals;
(B) Be
detailed enough to allow a qualified person to follow the course of
treatment;
(C) Be completed as they
occur for individual, IOP, and group therapy sessions. The dates of services
shall be documented as part of each individual or group therapy session
progress note; and
(D) Be signed by
the staff providing services to the client. If the staff is not a qualified
clinical staff the progress notes shall also be signed by a qualified clinical
staff;
(xi) Releases of
client confidential information completed in full and signed by the client or
legal guardian and the provider;
(xii) Referrals;
(xiii) Quality of care reviews;
(xiv) Correspondence relevant to the client's
treatment, including all letters and dated notations of telephone conversations
conducted by provider staff;
(xv)
Documentation of any prescribed medication, to include:
(A) The client was fully apprised about the
medication;
(B) The assessment for
the medication;
(C) Each prescribed
medication;
(D) Medication
monitoring; and
(E) If the client
is receiving MAT from another provider, documentation of collaboration and
attempts to collaborate with the qualified provider of MAT;
(xvi) Evidence the client was
given information regarding communicable diseases, referred for screening, and
provided linkages to appropriate counseling; and
(xvii) Documentation of continued stay,
transition, and discharge planning, including the ASAM level of care
recommendation. Discharge summaries must contain a summary of pertinent case
record information and any plan for continuing care, referral, or admission to
another level of care.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.