Recipient Records Requirements

(1) The individual record for each service recipient must also contain the following information: (a) Progress notes which must include written documentation of progress and changes that have occurred within the plan of care and, at a minimum, are documented daily. Progress notes must be dated and minimally include the signature, with title or degree, of the person preparing the note. (b) A discharge summary which includes primary diagnosis, secondary diagnosis (when appropriate), clinical summary, condition at time of discharge or transfer, and aftercare arrangements and recommendations. (c) Results of assessments required by 0940-05-33-.05 (d) Individual Plan of Care (e) Standardized diagnostic formulation(s) including, but not limited to, the current Diagnostic and Statistical Manual (DSM) and/or ICD-9.