Client Record Requirements For Outpatient Facilities

(1) An individual client record must be maintained which includes the following: (a) Progress notes which must include written documentation of progress or changes which have occurred within the IPP and which must be developed after each service contact; (b) Documentation of all drugs prescribed or administered by the facility which indicates date prescribed, type, dosage, frequency, amount and reason; MINIMUM PROGRAM REQUIREMENTS FOR MENTAL CHAPTER 0940-05-14 HEALTH OUTPATIENT FACILITIES (c) Narrative summary review of all medications prescribed at least every six (6) months which includes specific reasons for continuation of each medication; and (d) A discharge summary which states, if appropriate, the client’s condition at the time of discharge and signature of person preparing the summary.