Section 63N-1.0042 - Active Mental Health/Substance Abuse Treatment File(1) Mental health and substance abuse records may be temporarily maintained in an Active Mental Health/Substance Abuse Treatment File during a youth's on-going mental health or substance abuse treatment.(2) When utilized, a youth's Active Mental Health/Substance Abuse Treatment File must be maintained in a designated secure filing area. The filing area must be accessible only to appropriate mental health and/or substance abuse staff, and designated administrative, supervisory and medical staff who have a need for the information in connection with their duty to monitor the youth's progress or to participate in the assessment and treatment of the youth.(3) The Active Mental Health/Substance Abuse Treatment File must be maintained until the Mental Health Clinical Staff Person or Substance Abuse Clinical Staff Person determines that the youth's on-going mental health or substance abuse treatment is completed, at which time the Active Mental Health/Substance Abuse Treatment File must be placed in the youth's Individual Healthcare Record. An exception is provided for facilities which provide Specialized Treatment Services or ongoing mental health or substance abuse treatment services. Such facilities may maintain an Active Mental Health/Substance Abuse Treatment File throughout the youth's placement in the facility/program. The Active Mental Health/Substance Abuse Treatment File must be placed in the youth's Individual Healthcare Record prior to the youth's transition from the program.(4) The Active Mental Health/Substance Abuse Treatment File must be restricted to documentation of mental health and substance abuse treatment of a non-medical nature. Documentation of administration and management of medication and medical services provided by a physician, physician assistant or nurse must be filed in the youth's Individual Healthcare Record. It is acceptable to retain a copy of documentation of Psychiatric Services such as a psychiatric evaluation to be placed in the Active Mental Health and Substance Abuse Treatment File. However, the original psychiatric evaluation must be maintained in the youth's Individual Healthcare Record.Fla. Admin. Code Ann. R. 63N-1.0042
Rulemaking Authority 985.64(2) FS. Law Implemented 985.601(3)(a), 985.14(3)(a), 985.145(1), 985.18, 985.48(4), 985.64(2) FS.