Individual Record Requirements

(1) The record for each service recipient must contain the following information: (a) Progress notes which must include written documentation of progress and changes which have occurred within the Plan of Care and, at a minimum, must be developed after each service contact. Progress notes must be dated and minimally include the signature, with title or degree, of the person preparing the note. (b) Results of assessments required by rule 0940-05-15-.03; and MINIMUM PROGRAM REQUIREMENTS FOR MENTAL HEALTH CHAPTER 0940-05-15 ADULT DAY TREATMENT SERVICES (c) Discharge summary which states, if appropriate, service recipient condition at the time of discharge and signature of staff person preparing the summary.