0940-05-37-.06
Record Requirements
Cite as Tenn. Comp. R. & Regs. 0940-05-37-.06
(1)
The individual record for each service recipient must contain the following information:
(a)
Documentation of the POC and the Individualized Education Program (if required) and
of their implementation;
(b)
Progress notes must be recorded daily, and must include written documentation of
service recipient progress and changes, which have occurred within the POC. The
progress notes must be dated and include the signature, title or degree of the person
who provided the service;
(c)
Documentation of all drugs prescribed and/or administered by the facility which
indicates date prescribed, type, dosage, frequency, amount, and reason;
(d)
Narrative summary review at least every six (6) months of all medications prescribed
which includes specific reasons for continuation of each medication;
(e)
Documentation of significant behavior; and actions taken by staff;
(f)
A list of each article of the service recipient’s personal property valued at one hundred
dollars ($100.00) or more, and its disposition if no longer in use;
(g)
Documentation of abuse, medical problems, accidents, seizures, and illnesses and
treatment for such abuse, accidents, seizures, and illnesses, and any reports
generated as the result;
(h)
Results of assessments required by this rule;
(i)
Discharge summary which states, service recipient’s condition at the time of discharge
and signature of person preparing the summary.
MENTAL HEALTH RESIDENTIAL TREATMENT FACILITY
CHAPTER 0940-05-37
FOR CHILDREN AND YOUTH
(j)
Documentation of an education plan developed for each service recipient that conforms
to the Rules, Regulations, and Minimum Standards of the State Board of Education
and the Individualized Education Program (IEP) test being developed by an
appropriately constituted IEP-Team for all “qualified students with disabilities.”
The education plan may include education services provided either by the facility or by
the local education agency.
(k)
Appropriate consents and authorizations for the release and obtaining of information
about the service recipient.