Program Records

Program Records

Per COMAR 10.47.01.08 WIN Team maintains electronic and hard copy medical records for each client that are maintained by the Administrator, reviewed and updated by the Addiction Specialist and Clinical Supervisor, and available for review by client upon request.  The client medical record includes:

  • Patient identifier (client name and medical assistance number)
  • Eligibility and Insurance Verification
  • Intake Form and supporting documentation
  • Clinical Assessment
  • Individualized Treatment Plans
  • Progress Notes
  • Critical Incident Reports
  • Discharge Summary

In accordance with COMAR 10.47.01.08A(2) WIN Team maintains 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, Annoted Code of Maryland, by the following:

  1. WIN Team maintains, transfers, and destroys all records in a manner consistent with the medical records confidentiality and disclosure requirements of:
    1. The Health Insurance Portability and Accountability Act (HIPPA)

Per COMAR 10.47.01.08A (2) b WIN Team medical records are located conveniently and available for designated WIN Team staff members.

Per COMAR 10.47.01.08A (2) c WIN Team Administrator is responsible for appropriate records control, including storage, security, and indexing records.

Management Information System

Per COMAR 10.47.01.08 B WIN Team participates in the Administration’s management information system, by complying with the reporting requirements as required by the Department and WIN Team clinical staff completes and submits the driving while intoxicated data collection form chosen by the Administration for those arrested for driving while intoxicated or driving under the influence.

Electronic Records

Per COMAR 10.47.01.08C WIN Team maintains electronic medical records according to requirements set forth in this regulation. WIN Team maintains a companion hard copy medical record at the program and the record contains the following information:

  • Patient identifier (client name and medical assistance number)
  • Eligibility and Insurance Verification
  • Intake Form and supporting documentation
  • Clinical Assessment
  • Individualized Treatment Plans
  • Progress Notes
  • Critical Incident Reports
  • Discharge Summary

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